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UE Medical English
Dr Duksha RAMFUL
Lesson 6 – Medical record, operative report and discharge summary.

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Medical record (history chart)

= Documentation of a patient’s medical history and care across time within

one particular setting. e.g during a hospitalization

• Includes notes entered over time by healthcare professionals

- Patient’s demographic details
- History of the disease, past history, review of symptoms (see lesson 3 :
interviewing the patient)
- Physical examination
- Investigations : test results, imaging findings, etc…
- Management
- Name, date of the observer(s)
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Example of a medical
record on admission

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Operative report (surgical report)

Report written by the surgeon in a patient's medical record to document the

details of a surgery.

Includes sufficient information to :

• identify the patient, surgeon, anesthetist

• identify the institution and facility
• state the date of procedure
• support the diagnosis (from medical history, physical examination to investigations)
• describe perioperative findings and surgical procedures performed
• document the postoperative course for continuity of care

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Operative report (surgical report) : Example

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Discharge summary

= clinical report prepared by a health professional at the conclusion of a hospital stay

or series of treatments.

• Primary mode of communication between the hospital care team and aftercare providers.

• Includes
- Patient details, admission and discharge dates
- General practitioner’s details
- Hospital/setting details
- Clinical details : history, examination findings, investigations, procedures, diagnoses,
management, complications
- Future management (e.g follow-up, discharge instructions)
- Medications
- Person completing report
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Discharge summary : Example

ED = Emergency department
COPD = Chronic Obstructive
Pulmonary disease
PO = per os

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Referral letter

= essential means of communication between primary and secondary

care, giving the receiving clinician/department a summary of the patient’s
problem to ensure a smooth transition of care.

Should include :
▪ Referral destination : Name of the receiving consultant and/or specialty
clinic/department
▪ Referring practitioner details : Name, speciality, address, telephone, fax
number, email,…
▪ History of patient : presenting complaint, PMH, investigations/management
up to date
▪ Reason for referral
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Referral letter : Example

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