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LNCtips.com: Organizing Hospital Medical Records

As an independent or in-house legal nurse consultant, you will likely organize many hospital medical records. You will receive hospital records in category order but they probably won't be in chronological order. Hospital records are usually in reverse chronological order because that is the way they are used in the hospital.

It's easier for attorneys to make sense of the chart if the sections are in chronological order (See General Tips).  The order of the chart sections is not set in stone and can be altered to your preferences. Below is one way in which hospital records can be organized. Each category in bold represents a tabbed chart section.

Admission

  • Admission face sheet

  • Consents, except operative consents

  • Inventory sheet

  • Living Will. Although this form may have been signed prior to admission, it can be placed behind documents from the admission date.

  • Durable Power of Attorney.  This form may also have been signed prior to admission.

  • Leave of absence forms.

  • Transfer forms generated by the hospital when it is sending a patient to a nursing home or another hospital. The transfer form can be the last form in this section.

  • Emergency Room Records

    History and Physical

    Discharge Summary. You can include both the physician and nursing discharge summaries or you can place the nursing discharge summary at the end of the nursing notes.

    Consultations (unless the consult notes are integrated within the Progress Notes)

    Orders

    Progress Notes

    X-Rays/EKGs

    Surgeries and Procedures. If more than one procedure or surgery occurred, group them chronologically by each procedure or surgery, separated by a tab or piece of colored paper. 

  • Typewritten operative reports

  • Pathology report (if there is one)

  • Anesthesia reports

  • Intraoperative reports

  • Recovery room

  • Operative consents

  • Nursing Assessment / Care Plans. The nursing assessment form can be placed first, followed by any other random assessments from the day of admission, followed by care plans.

    Nursing Notes

  • If there are flow sheets that are separate from the nursing notes, the flow sheets can be grouped to precede or follow the nursing notes.

  • For multiple-paged flow sheets, ensure that each date has all forms in the same order.

  • Medication Administration Records (MARs)

    Pressure Ulcer/Skin Reports

    Graphic Sheets

    Intake and Output Sheets

    Therapies. These include Physical Therapy, Occupational Therapy, Speech Therapy, and Respiratory Therapy. Group chronologically by each therapy separated by a tab or piece of colored paper.

    Social Services / Case Management / Discharge Planning.

    Once you have organized the medical records, put them in a three-ring binder with tabs separating each section.

    ...Katy Jones