Self Instructional Manual for Cancer Registrars - SEER - National ...

ORGANIZATION OF A MEDICAL RECORD
Each hospital has its own procedures for organizing a medical record. Most of the time this will be done
by the medical record department. Usually, the record will be organized in terms of the temporal sequence
of events with the latest admission located at the front of the medical record. After the patient is discharged
from the hospital, a summary of the patient's diagnosis and treatment may be prepared by the attending
physician and inserted at the front of the medical record. This can be used as a guide to ensure that you
have not overlooked any reports. However, you should abstract directly from the actual reports in the
patient's record, not from the discharge summary. The discharge summary is an overview of the patient's
hospitalization from the point of view of the attending physician. It is usually dictated after the patient is
discharged from the hospital, possibly from inadequate notes or an incomplete medical record.
In some hospitals a copy of the cancer registry abstract is kept in the patient's medical record. It acts
as a handy summary of the patient's history, diagnosis, and treatment. Not only is this a useful service to
physicians, but it makes them aware of the registry as a source of cancer data available in their own hospital.
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