Chapter: 4.2 Medical Records: content

Medical Records: content
Content of hospitals' records are quite exhaustive. They include

i)    Registration and administrative data (Name, sex, age, occupation income, Date & time etc.)
ii)    Diagnosis, investigations and operation, clinical notes, progress including birth details.
iii)    Condition on discharge & final diagnosis
iv) Causes of death, date and time of death
v)  Discharge card giving details of clinical history, progress, investigation done and treatment given.
vi) Investigations & reports
vii) USG (Ultrasonography) reports
vii) Consent forms
viii) Operation notes
ix) Referral notes
x) Discharge summary, etc.