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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 because
of the difficulty in deciphering physician's handwriting.
If you know your root words and how to use your medical
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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.
Composition of a medical record
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)
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