The patient’s record is customarily organized according to the components of the history, physical examination, diagnostic summary, plan of treatment, and medical risk assessment described in the preceding pages. Test results
(diagnostic laboratory tests, radiographic examinations, and consultation and biopsy reports) are filed after this, followed by dated progress notes recorded in sequence. Separate sheets for (1) a summary of the medications prescribed for or dispensed to the patient, (2) a description of surgical procedures, (3) the anesthetic record, and (4) a list of the patient’s problems and their proposed and actual treatment are also incorporated into the record.This pattern of organization of the patient’s record may be modified according to local custom and to varying approaches to patient evaluation and diagnostic methodology taught in different institutions.