Medical Record Organization

What Works: Effective Practices for Office-based CareComponents of the Medical Record
Medical Record Organization

Recommendation: Medical record is organized in a standard format with easily identifiable components.

Source: CRICO/RMF Office Practice Handbook


 Effective Practice
Colored dividers for paper systems.
Benefits:
  • Easy retrieval of medical record information
  • Improves proper filing by category and date
In practice at: MAH Atlantic Healthcare


 Effective Practice
Paper or electronic records with tabbed systems and entries sub-filed by date under each tab
Benefits:
  • Elements can be easily retrieved
  • Entries are filed by date-of-service
In practice at: Paper system: Multiple practices, Electronic System: HVMA (all sites), CHA (most sites)


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