A medical record is composed of a number of sections. The first section contains a description of the patient’s complaints and symptoms, the medical history of the patient, the findings of a physical examination of the patient, and the impressions of the examining physician regarding the diagnosis of the patient’s illness.
You should be cautioned that each medical record will be slightly different. The order in which information is recorded will be slightly different and sometimes certain items of information will not be found in the medical record as more patients are diagnosed and/or treated in the physician’s office or in a clinic. It must also be noted that medical practitioners are not noted for their penmanship. Indeed, perhaps one of the most difficult aspects of medical record abstracting is deciphering the physician’s handwriting. This will be less of a problem as more hospitals computerize the medical record. The United States military is considering a computerized system called Composite Health Care System (CHCS). Army hospitals in Kentucky and Hawaii began developing the system in 1988 as well as Navy and Air Force facilities. Now the system is being tested in Walter Reed Medical Center, the Army’s largest teaching hospital. It will eventually be installed throughout military medical centers — a total of 125 hospitals in the United States.
The first entry in the record is usually a description of the chief complaints (CC) of the patient, i.e., the reason the patient sought medical attention. The description of the present illness (PI) which follows includes a description of the onset of the illness and the symptoms associated with it.