LNCtips.com: Organizing Hospital Medical Records
Most hospital records are now in electronic format. The easiest way to organize electronic records is to leave them in order. In other words, no organization is necessary. However, if you receive non-electronic medical records, they will likely be 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.
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)
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.
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
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.