Medical Chart Summary English

There are frequently difficulties with Russian medical summaries. This problem is addressed in our page devoted to Russian medical reports. The form below is designed to deal with several problems

1) Important information is often absent or undated,
2) diagnoses are frequently written without elaboration, and are therefore inadequate for making an assessment,
3) medical summaries suffer from including too much vague and unhelpful information.

This form is designed to elicit the maximum useful information from a chart review, to prompt or remind the reviewing physician to look for specific items of information, and to require justifications and explanations for diagnoses written.

The Russian version of this form is available with identical format and numbering. You will need cyrillic fonts installed on your computer.

Developmental assessment outline with Russian translation is now available. To be addressed soon is the actual physical examination. This will be added in the near future. Suggestions and help with this project are certainly welcome.

Finally, a Microsoft Word version of this form may be obtained by email request.

Medical Summary Form

1. Child

Last Name _________________ First ____________ M.. ______________

Birthday	_{___/___/___}	Age: ____	Summary by: ________________________
	D/M/Y		Date of Summary: _{___/___/___}

Orphanage	_________________________	Name of Director	___________________	tel.______________
	_________________________

2. Prospective adoptive parent(s)

Name __________________________

Address _________________________

_______________________________

Expressed special concerns:

_{______________________________________}

3. Agency

Name ______________________________

Representative _________________________

Contact Numbers ___________________

4. Historical Information from Medical Record

Known current problems ____________________________________________________

Born at _____ weeks gestation; Apgars _______ ; Type of Delivery ___________

Known Problems at Delivery ______________________________________________________

5. Pregnancy Notes from Record

______________________________________________________________________

6. Perinatal Course if Known

______________________________________________________________________

7. Documented History of Maternal Alcohol or Drug Use Y/N If yes, details

______________________________________________________________________

8. Growth Measurements from Chart

Weight	Height	HC	Chest	Date (D/M/Y)
______	______	______	______	_{___/___/___}
______	______	______	______	_{___/___/___}
______	______	______	______	_{___/___/___}
______	______	______	______	_{___/___/___}

(HC = Head Circumference. Weight in kilograms, height and HC in centimeters)

Entered orphanage	___________	Reason _________________________
	D/M/Y

9. Family History (if known)

Siblings ___________________________________________________________________

Parents, relatives ____________________________________________________________

_________________________________________________________________________

10. Previous Medical History and Diagnoses from Medical Record

Diagnosis	Date of Diagnosis	Basis of Diagnosis (physical findings, diagnostic tests, etc)	Current Status
_____________________	__ / __ / __	_______________________________ _______________________________	________________ ________________
_____________________	__ / __ / __	_______________________________ _______________________________	________________ ________________
_____________________	__ / __ / __	_______________________________ _______________________________	________________ ________________
_____________________	__ / __ / __	_______________________________ _______________________________	________________ ________________
_____________________	__ / __ / __	_______________________________ _______________________________	________________ ________________
_____________________	__ / __ / __	_______________________________ _______________________________	________________ ________________

11. Treatments Received for Illnesses Above

_______________________________________________________________________

12. Hospitalizations with Dates and Diagnoses

_______________________________________________________________________

13. Known Allergies ______________________________________________________

14. Surgery _____________________________________________________________

15. Current Medications __________________________________________________

16. Current Illness(es) if Any ______________________________________________

_______________________________________________________________________

17. History of Transfusion or Parenteral Injections _____________________________

18. Diet ________________________________________________________________

19. Toilet Habits ______________________________________________________

20. Vaccinations

Vaccination	Date
__________________________	_{___/___/___}
__________________________	_{___/___/___}
__________________________	_{___/___/___}
__________________________	_{___/___/___}
__________________________	_{___/___/___}
__________________________	_{___/___/___}
__________________________	_{___/___/___}

21. Sources of Information other that the Medical Record

___________________________________________________________________________

22. Behavior, Development and Habits
(recorded observations of milestones such as sitting, crawling, play behavior, vocalizations, social interactions, etc. (with dates)).

______________________________________________________________ ___/___/___

Signature of Physician _____________________ Date ___/___/___

Note: Please ensure that all dates are in Day/Month/Year format. If information requested is unavailable, please state this explicitly on form.

Medical Chart Summary Form

To Russian Version | To Adoption Main Page | Developmental Assessment Outline

Return to Top | Russian Version | Adoption Main Page | Developmental Assessment Outline