The standardisation of hospital medical records / report of the sub-committee.

  • Great Britain. Standing Medical Advisory Committee.
Date:
1965
Catalogue details

Licence: Public Domain Mark

Credit: The standardisation of hospital medical records / report of the sub-committee. Source: Wellcome Collection.

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    GLOSSARY OF MEDICAL RECORD TERMS COMMONLY USED I. General (i) A Medical Record Any document on which information about a person in a_ professional relationship with a doctor is recorded. (ii) Case Papers A dossier comprising medical record (Sometimes known as The Medical documents of an individual, patient. Record) (ili) Case folder A folder enclosing the patient’s case papers. IJ. Primary Documents(!) (i) Identification Sheet A form containing the personal and (Formerly known as the Front administrative details relating to an Sheet) individual patient, and to the discharge diagnosis. (ii) (a) Discharge Summary A statement completed by the con- sultant or his assistant on the discharge or death of the patient containing a summary of the significant findings, results of investigations, treatment, pro- gress, and disposal of the patient. (ii) (b) Post-mortem record The pathologist’s report of the post- mortem examination including, where - appropriate, a record of the histological or other laboratory examination of post mortem material. (ii) Discharge Letter ~ A letter sent by a hospital doctor in- forming a _ patient’s general prac- titioner of the patient’s discharge from hospital. It also contains details of diagnosis, treatment and drugs recom- mended, and information given to the patient and/or relative. In minor cases the letter can take the place of the dis- charge summary. (iv) General Practitioner’s Letter of A letter from a general practitioner to referral a hospital requesting a consultation appointment for his patient. It may contain the general practitioner’s clini- cal note for the consultant. (v) History Sheet (and Continuation The part of the patient’s case papers Sheet) containing the doctor’s clinical notes and details recorded by the doctor of the patient’s treatment and progress. (vi) (a) Operation and/or Anaesthetic A record of a surgical operation and Record of the associated anaesthetic procedure (vi) <b) Consent Form A form signed by the patient (or the patient’s representative) consenting to the performance of an operation and the administration of an anaesthetic. (1) See paragraph 22.