Newsletter

Volume 1, No 6

Suggested Medical Record Order For Medical-Surgical Cases

Admission Records and Consent Forms
Death Certificate
Autopsy Report
Discharge Summary
Emergency Room Records
Admission History and Physical
Consult Reports
Operative Records (including Anesthesia Record)
Recovery Room Records
Pathology Reports
Medical Progress Notes
Medical Orders
EEG Reports
Echocardiogram Reports
12-Lead EKG Reports
Myelogram Reports
EMG Reports
Radiology Reports
ABG Reports (if separate from other lab)
Lab Reports (flow sheets go in front)
Nursing Care Plan
Nursing Notes (ICU separate from General Units)
Nursing Discharge Note
Cardiac Arrest Records
Neuro Vital Signs Records
Nursing Flow Sheets
I & O Records
IV Medication Records
Medication Records
Vital Signs Graphic Records
Respiratory Therapy Records
Physical Therapy Records
Occupational Therapy Records
Social Worker Records
 

  Medical Record Order Recommended by the National Medical-Legal
 Consulting Institute, Inc.  in Houston, Texas