Medical Record Forms
The medical record is made up of a number of forms, which are all used for a specific
purpose. The basic set of forms in the inpatient medical record includes:
• front sheet or identification and summary sheet, which covers identification, final
diagnoses, disease and operation codes, and the attending doctors signature;
• consent for treatment is often on the back of the Front Sheet and must be signed
by the patient at the time of admission. There are two parts to this form. The first
half of the form is a general consent for treatment and the bottom half is consent to
release information to authorised persons;
• correspondence and legal documents received about the patient, e.g., referral letter,
requests for information, etc.;
• discharge summary, if required by the hospital/health authority;
• admission notes, including the patient’s family medical history, the patient’s past
medical history, presenting symptoms, results of a physical examination, provisional
diagnosis (the reason the patient came or was brought to hospital), proposed tests
and care;
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