Organization of a Medical Record

Each hospital has its own procedures for organizing a medical record. Most of the time this will be done by the medical records department, also known as the Health Information Department. Usually, the record will be organized in terms of the temporal sequence of events with the latest admission located at the front of the medical record. After the patient is discharged from the hospital, a summary of the patient's diagnoses and treatments may be prepared by the attending physician and inserted at the front of the medical record. This summary can be used as a guide to ensure that reports are not overlooked. Abstracting shoud, however, directly be done from the actual reports in the record and not from the point of view of the attending physician. Usually, dictation occurs after the patient is discharged from the hospital, possibly from inadequate notes or an incomplete medical record.