Occasionally, the investigator must personally review a medical char,. but rarely does the entire medical chart need to be reviewed in order to understand the diseases and death of a patient. The most important information can usually be obtained from the following:
1. Discharge summary. A summary of everything done to the patient and how the patient presented to the hospital. It will also tell about the death or the condition of the patient when discharged and the medications the patient was receiving. If the person dies in the hospital, the discharge summary may not have been typed before the information is needed. If not available, the physician should be contacted.
2. Physician's notes. Brief summaries of the day-today progress of the patient and what the physician thinks about the patient's course during hospitalization.
3. Nurse's notes. Shift notes. They may be the best indicator of how the patient was doing at a particular time of the day. Nurses make many notes during the day of the patient's progress, while a physician may only write one note during each day, if that often.
Was this article helpful?