Glossary

Medical record: The medical record is where all the information on a patient is kept. The medical record may be in a hospital, surgery center, radiation center or doctor's office. Medical records can be very simple, or extremely complex. The following is a list of specific types of information contained in most medical records. The information will not necessarily be in this order. Patient identification Referral information Biographical information Medical history: chief complaint, review of systems, personal medical history, family medical history Provisional diagnosis (admitting diagnosis, first impression) Special examinations Pathologist's reports Final diagnosis Treatment (therapy) reports Progress notes Discharge (narrative summary) Follow-up reports Autopsy report (gross and microscopic) Death certificate