Composition of a Medical Record

A medical record may be quite simple, containing only a few pages; or it may be extremely complex containing a variety of reports, some of which may be handwritten. It is imperative that you master medical terminology to the best of your ability not only because of the unfamiliar terms you will encounter, but also because of the difficulty in deciphering physician's handwriting. If you know your root words and how to use your medical dictionary, you can generally decipher most medical terms.

Other portions of the medical record may be referred to for clues as to what the incomprehensible term might be. Request assistance from your medical consultant when necessary. In any case, familiarize yourself with the diagnostic procedures used in your hospital so that you are aware of missing or incomplete information. Medical records have certain characteristics in common. It is these fundamental characteristics which you will study in this block of instruction.

The following is a list of specific types of information contained in most medical records. The information will not necessarily appear in this order.

Patient Identification

Referral Information

Biographical Information

Medical History

  • Chief complaint (CC) (date of onset and description of symptoms)
  • Review of Systems (R.O.S)
  • Pregnancy history
  • Personal medical history (to include medically-related social history, for example, drinking, drug habits, smoking and exposure to other carcinogens)

Physical Examination

  • General (general patient description by MD)
  • Head
  • Eyes
  • Ears
  • Nose and Sinus
  • Mouth
  • Throat
  • Neck
  • Thorax
  • Lymph nodes
  • Cardiovascular System
  • Lungs
  • Breasts
  • Abdomen
  • Genitourinary System
  • Rectum
  • Bones, Joints, and Muscles
  • Nervous and Mental State (neurological condition)
  • Extremities

Provisional Diagnosis (admitting diagnosis, first impression)

Special Examinations

  • Radiologic Examinations (diagnostic x-rays)
  • EKG (electrocardiogram)
  • Diagnostic Imaging Nuclear Examinations (scans)
  • Laboratory Reports: Urinalysis, hematologic analysis* (blood chemistries), other chemistries, serology and cultures
  • Consultation Reports
  • Endoscopic Examinations
  • Exploratory Surgery

Pathologist Reports

  • Exfoliative Cytological Examinations
  • Tissue Examinations
    • Gross (description based on visual examination)
    • Microscopic (description based on histologic examination) Pathologic Diagnosis (determining the disease)

Final Diagnosis (made after all routine and special studies have been completed)

Treatment (therapy) Reports

  • Medication record (drugs or other medications)
  • Surgery (report of surgery, operative report)
  • Radiation therapy
  • Chemotherapy
  • Immunotherapy
  • Hormonal therapy
  • Physical therapy

Progress Notes

  • Doctor's orders
  • Nurse's notes
  • Social worker's notes
  • Occupational therapy
  • Physical therapy
  • Hospice notes

Discharge (Narrative) Summary

Follow-up Reports

Progress notes added after the patient has been discharged from the hospital:

  1. Based on patients return visits to outpatient departments
  2. Based on replies to correspondence with patient's physician, other tumor registrars, other medical facilities, with the patient or with the patients family

Autopsy Report (gross and microscopic)

All of the major organs and systems are examined unless the autopsy is restricted to certain organs. Any pertinent findings should be recorded on the tumor registry abstract. The information can be of particular value in indicating the primary site of the tumor, which may have been incorrectly diagnosed or unknown prior to autopsy.

Death certificate (when the patient dies in the hospital or when the death certificate is obtained through follow-up activities)

* Simultaneous Multiple Analysis may be used-This is an automatic analyzer that measures chemistries. For example, SMA-6 may measure sodium, potassium, chloride, carbon dioxide, BUN, glucose and creatinine. SMA-12 may measure calcium, alkaline phosphatase, SGOT, bilirubin, phosphate, LDH, uric acid, creatinine, BUN, total protein, albumin, glucose and cholesterol.