Hospital Records – How They Are Organized

by | Published on Nov 12, 2012 | Medical Record Review

Attorneys involved in medical litigation usually require organized hospital records. Legal nurse consultants and medical record review firms assisting attorneys arrange medical records in chronological order to facilitate clear understanding of the case. Organizing hospital records is important also from the viewpoint of ensuring accuracy and completeness of these documents.

Medical records need to be organized according to the category.

  • Admission reports: these include the admission face sheet; consents other than operative consents; inventory sheet; Living Will; Durable Power of Attorney; Leave of Absence forms; and Transfer forms, in that order.
  • Emergency room records: these are records that accurately present the processes of evaluation, management, and medical decision making. They also highlight the disposition of the patient. ER records make quality assessment, quality improvement and risk management processes easy.
  • History and Physical records: these are the basic documents pertaining to all newly admitted patients for in-patient as well as outpatient service. They present the main complaint, history of present illness (HPI), past history (medical and psych), social &family history, list of medications, ROS (review of systems), physical & mental status exam, assessment & plan (Recs)
  • Discharge Summaries: these will include both the physician and nursing discharge summaries. The nursing discharge summary can also be placed at the end of the nursing notes.
  • Consultations: include physicians’ consultations among each other regarding diagnoses and/or treatment. Reports include reason for consultation, review of past and current history, review of medication, exam and an assessment and recommendations.
  • Orders
  • Progress notes: these are daily notes the physician makes on hospitalized patients.
  • Radiology and other reports
  • Surgeries and procedures: these will be arranged in the order they took place and include operative reports, pathology report, anesthesia reports, intra-operative reports, recovery room reports, and operative consents
  • Nursing Assessment/ Care Plans: Nursing and other random assessments right from the day of admission are placed first, and the care plans after those
  • Nursing notes
  • Medication administration records (MARs)
  • Skin/Decubitus reports
  • Graphic sheets
  • Intake and output sheets
  • Therapies provided: for instance, record of physical therapy, speech therapy, occupational therapy and respiratory therapy.
  • Social Services / Case Management / Discharge Planning

It is important to organize voluminous medical records so that all medical aspects are clearly understood. A medical record review company would carry out a detailed review of the records to create a medical chronology, and medical case history and summary. Proper organization of medical records would also help to spot missing records, to ensure that a particular set of medical records are for the intended patient, and that no mix-up has occurred.

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