Here's a list of section divisions that will let you organize pretty much any US hospital chart. Not every chart will include every section, but for stays lasting more than a week charts usually use 12 to 15 of the tabs we've listed for you here. (You'll find a printable, copy-and-pasteable version of these section tabs at Printable Lists.)

If the person had several different hospital stays be sure you organize each separate admission with its own set of section tabs, and clearly mark the different admissions! This simple confusion avoidance technique is a huge expert-billable-hours saver.

Sending the records already snapped into a 3-ring binder is another big expert time (aka 'money') saver .

Invest the time to date order the pages in important sections. The specifics of the case and the text here will help you decide which those are.

Chances are the records as they come to you will already be sorted into these categories -- you'll just need to add section tabs and do a little shuffling. As with most things the last five percent takes 90 percent of the effort, so we've included keywords to help you demystify where-the-heck-does-this-go pages.

GOOD LUCK!

Hospital and Insurance Admission Paperwork	1	Keywords: Admission, Physician Attestation Form Expect a generic Consent to be Treated at the hospital and plenty of insurance paperwork including a list of final diagnoses to be signed by the admitting (main) doctor. You're paying your expert to review the medical facts not the billing history, so keep this medically irrelevant stuff in it's own section out of the way.
Consents	2	Keywords: Consent, Consent to Procedure Consent forms for each procedure done during hospitalization. If the person had just one or a few procedures, it makes sense just to file the consent with the operative record. As the number of procedures grows it gets easier just to put all the consents in one place. Suit yourself.
Emergency Room	3	Keywords: Emergency Room / Department, ER, ED If the person was seen in the emergency room before being admitted to the hospital, you'll need a separate section for the ER records.Thanks to the incisive gray cells of some wunderkind MBA you'll likely find a few critical test results only here in the separate ER record, not in the hospital record where you'd reasonably expect them. Where you put those test results is a matter of your personal preference. Your choices: here in the ER section, or in the lab/path and x-ray sections of the chart. Either way works.
History & Physical and Discharge Summary	4	Keywords: History & Physical, H & P, Discharge summary, D/C summary An important section for you to organize well because this is a great place for your expert to get oriented to the case. These documents are usually typed, easy to read, and comprehensive. History and Physical: When the person first came into the hospital a doctor asked detailed questions reviewing their Chief Complaint -- their current illness -- and their entire medical history. He/she also did a detailed physical exam and developed an Assessment -- a list of active medical problems -- and a Plan of testing and treatment. Discharge Summary: An overview of the entire hospital stay, including all diagnoses, test results, surgeries, treatments, follow up plans, and discharge medications.
Consults	5	Keywords: Consultation, Consult, I've been asked to see the patient Another critical section for you to organize and label. Each specialist called in to consult on a case dictates a detailed report summarizing facts, making a diagnosis, and recommending testing and treatment. These documents are usually typed, easy to read, and comprehensive. This is another great place for your expert to get oriented to the case.
Doctors Orders	6	Keywords: Doctors' orders, Physician Orders In the hospital every pill, every test, every treatment, consultation, IV drip, every change in oxygen flow rate and even every packet of salt on the supper tray begins life as an order written in this section of the record by a medical doctor. These critical pages let you and your expert reconstruct exactly what the doctors did and when. Many hospitals use special two-column pages to combine doctors' orders and doctor's progress notes in one section of the chart.
Doctors Progress Notes	7	Keywords: Doctors' / Physician Progress Notes This critical section records what the treating doctors were thinking and doing each hospital day. And, by exclusion, what they weren't. Standard practice is to note the time each note was written. May be on sheets labeled 'Progress Notes,' but many hospitals use special two-column pages to combine doctors' orders and doctor's progress notes in one section of the chart.
Nurses' Notes	8	Keywords: Nurse, Nurses, Nursing, Vital Signs, I & O The doctor may be with a patient ten minutes a day, but twenty-four hours a day one or more nurses are on duty recording the patient's status in minute detail. Did their bowels move? Did they finish supper? Do they hurt? Nurses will note if the doctor was called about worsening pain and labored breathing; they'll also note if he came in to examine the patient or if he just gave a phone order, rolled over and went back to sleep. Medical malpractice cases have been be won or lost on facts recorded nowhere else but this important section of the hospital chart. Nurses fill out forms till their arms ache, so this vast section of the chart is always tricky to organize. Intensive Care Unit forms are different from general medicine ward forms, are different from post-op forms, are different from Ob-gyn ward forms, and so on. You'll likely have several different nursing forms for each hospital day. There's no right way to handle this. Do whatever seems to work best - any organization at all will improve on the jumble you start with. The only way to do it wrongly is not to do it at all.
Operative Notes	9	Keywords: Operative Report, Intra-operative record, Anesthesia record, Operation, OR, anesthesia, PACU, Post Anesthesia Care Unit, Post-op, Pre-op checklist. Standard practice is for the surgeon to walk from the OR to the Doctor's Lounge, pick up a house phone and dictate an Operative Report. The anesthesiologist generates an anesthesia record while the surgery is underway. The nurses in the PACU fill out forms. You'll want to file all this under the Operations tab. One operation can generate 10 - 20 pages of charting. That's not to much to flip through to find what you want, so don't bother sub-tabbing the op-report, the PACU record, the anesthesia record, etc. Just put the Op-note in front and everything else behind. But do be sure you separate, sub-tab and clearly label (by date will do) each and every surgery and procedure. This simple confusion avoidance technique is a huge expert-billable-hours saver.
Lab & pathology	10	Keywords: Laboratory, pathology, chemistry, hematology, microbiology It's not a bad idea to separate and sub-tab the few pathology reports from the many lab results, but in most cases it's not worth your time to separate all the chemistries from the hematologies from the micros. Do put the chemistries in date order, the micros in date order, etc. If the person got lots of transfusions it may be worthwhile separating those out at the end of this section, just to get them out of the way.
x-ray	11	Keywords: radiology, roentgenography, x-ray, CT, MRI, ultrasound, nuclear medicine, echocardiogram You can date order reports from the radiology department, or separate all the CTs from all the x-rays from all the MRIs. Either way works. Do date order this section.
EKG	12	You'll recognize these by sight. Keywords: EKG, ECG, electrocardiogram In most cases they don't matter much. Giving them their own section keeps them out of they way, and makes them easy to find if your expert does need them.
Autopsy	13	Keywords: autopsy A single document. Read it yourself before you invest in an expert opinion.
medication record	14	Med records have a formal layout you'll learn to recognize by sight. Keywords: medication record. A busy nurse hands out scores of pills each shift. Too many to keep straight in her head. She keeps track of who gets what pills when by referring to each patient's daily medication record kept in a loose leaf notebook on the meds cart. Every time she gives a pill or hangs an IV, she marks and initials the medication record. Now you've got that record. If your case depends on exactly what medicines the patient got, in what doses and when, this is a critical part of the chart you'll want to date order. You should carefully reconstruct the daily sequence to look for the dog that didn't bark - med sheets from around the time a patient was given the wrong drug have been known to disappear.
Physical Therapy and Occupational Therapy	15	Keywords: Physical therapy, occupational therapy, PT, OT Sometimes house great treasure, but usually irrelevant. Keep them out of the way. If they matter, here they are.
Respiratory Therapy	16	Keywords: Respiratory therapy. RT. Ventilator. Sometimes house great treasure, but usually irrelevant. Keep them out of the way. If they matter, here they are.
Computerized records	17	You'll recognize these by sight. Keywords: computerized record It's fashionable to program hospital computers so they spew page after page of minutely printed after-the-fact treatment summaries. I've seen these records printed twenty lines to the inch -- the same dimension as the threads on a 1/4 inch machine bolt! This format has nothing to do with actual treatment, it's pure hospital CYA. Computerized data entry is prone to dry-labbing. Still, these never-touched-by-human-hands pages may house great treasure. They almost always come pre-sorted, so just punch 'em, tab 'em, and stick 'em in the binder.
Miscellaneous	18	Count on having a few unclassifiable pages.