Review: The Composition & Organization of a Medical Record

Here is what we have learned from The Composition & Organization of a Medical Record:

  • A medical record may be quite simple or extremely complex, containing some information handwritten by physicians hard to decipher.
  • It is imperative for an abstractor to be familiar with medical terminology and diagnostic procedures to be able to abstract pertinent information from a medical record.
  • The information contained in most medical records includes patient identification, referral information, biographical information, medical history, physical examination, etc.
  • Forms, record notes, and summary sheets in the hospital's record may or may not contain relevant information for filling out a cancer registry abstract.
  • Examples of forms, record notes, and summary sheets include, but are not limited to, admission sheet, autopsy report, cytology report, endoscopy report, and pathology report.
  • Each hospital has its own procedures for organizing a medical record, and most of the time this is done by the medical records department.
  • Usually, the record is organized in terms of the temporal sequence of events.