Criminal Defense & Medical Malpractice Consultation
Medicare Prosecution Defense


Home Portfolio

Components of a Hospital Medical Record – A Checklist

Medical records are a critical component of the medical negligence case. Since they are often the best evidence of a departure from the standard of care, be sure you have received all pertinent documents when you request a client’s record. The following is a checklist of documents that comprise a patient’s hospital medical record.

Identification Sheet

This is the first page of the record and is filled in at admission, at discharge, and when the records’ custodian certifies the chart is complete and files it in the hospital’s medical records repository. At admission, clerks fill out this form with background information such as employment and insurance data and an admitting diagnosis. Following discharge, the form is completed with information on final diagnosis, complications suffered, surgical procedures performed, and verification by an attending physician that he or she checked the chart to ensure it met all state and federal requirements.

History and Physical Examination Records

Hospitals require a history and physical examination be completed on every patient admitted. The history generally contains a detailed description of the cause of the injury or disorder. It also details the patient’s work history, disabilities, pre-existing symptoms, chronic medical problems, and prior medical care.

Consent Forms

These may include consent for surgery, anesthesia, surgical sterilization, post-mortem examiantions, and other procedures. The forms are executed at admission and at other appropriate times during the patient’s hospitilization.

Physician’s Progress Records

This is the physician’s chronological record of developments that occur during a patient’s hospital stay. The attending physician or house staff usually dictates or writes notations in the record during hospital rounds or when there are significant changes in the patient’s condition.

In some hospitals, nurses maintain separate notes; in others, they write in the physician’s progress report. Nurses’ notes include general observations of the patient and are recorded during each shift. These notes include:

  • observations of the patient’s physical, mental, and emotional states;
  • special events such as urgent calls to physicians and sudden changes in a patient’s condition;
  • medications given, dosages, and the time and method of administration as ordered by the physician;
  • vital signs such as blood pressure and pulse and respiration rate at intervals ordered by the physician;
  • the patient’s food intake and bowel and bladder functions; and
  • a discharge note explaining the plan for home care and clinic follow-up.
Physician Order Sheets

The physician writes instructions to the nursing staff for the patient’s care on an order sheet.
Orders may involve:

  • diet;
  • medications and intravenous fluids to be administered;
  • laboratory tests; and;
  • frequency that vital signs are to be taken.
Laboratory Reports

Reports of diagnostic studies, such as X-rays and electrocardiographs, are sent to a patient’s unit and added to the hospital record. The department that issued the report keeps a copy on file.

Consultation Reports

Often, the attending physician will ask a consulting physician to give an opinion, assist in the patient’s management, or take over some aspect of the care. Consultation reports document the consultant’s findings and opinions. In some cases, the consulting physician will not prepare a separate report but will add a note to the attending physician’s progress record.

Discharge Summary

This is the attending physician’s summary of the patient’s entire course of hospitilization and, thus, provides an excellent overview. It contains a restatement of the admitting history and physical examination, the patient’s hospital course, diagnoses, results of diagnostic studies, treatment given, and outcome.

The summary should be dictated and transcribed on the same day a patient is discharged. The date this occurs usually appears in the lower left or right of the document. Compare this record to the clinical chart to identify potential discrepancies.

When you receive a patient’s medical records, always be sure you have all the pertinent documents. Then, review them with an eye toward whether they tell a complete and consistent story of the patient’s stay. Inconsistencies or gaps may point to medical negligence, and the records will help you prove your case at trial.

Components of a Hospital Medical Record – A Checklist
by Elliott B. Oppenheim
Elliott B. Oppenheim, M.D., J.D., L.L.M. Health Law, is a student ATLA member from Grosse Pointe, Michigan, and president of MedIntelNet, Inc., a national medical-legal consulting corporation.

Reprinted with permission

Copyright © 2016 MedIntelNet. All rights reserved.