COMPONENTS OF A MEDICAL RECORD
I. Admissions Record.
Patient's name and age.
Reason for admission.
Pertinent medical history.
II. Clinical Record.
Diagnoses (admitting and subsequent).
Temperature chart.
Consultations.
Medical notes.
Laboratory test results.
X-ray readings.
Surgical and delivery records (anesthesia reports, operative procedures and
Nursing notes.
One-page summaries (of entire hospital stay).
Condition at discharge.
Figure 3-1. The admissions record, the first part of the medical record, is compiled
when the patient is admitted. The clinical record, the second part of the
record, is a continuing history of patient treatment and physical history.
MD0067
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