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).
Laboratory test results.
Surgical and delivery records (anesthesia reports, operative procedures and
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.