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Best Practices for Reading and Understanding Different Parts of a Medical Record


Gain a better understanding of medical records and what types of information they contain.

This topic will help you be able to organize, read and understand the information contained in various parts of the medical record in an efficient manner. You will be able to identify the forms in which medical records are contained as well as the contents of medical records. The material will help you with organizing medical records as well as how to understand each part of the medical record. Finally the information will help you be able to systematically follow the admission process, diagnosis, treatment(s) and discharge of clients.



James Maisel, M.D.

James Maisel, M.D.

ZyDoc Medical Transcription, Retina Group of NY

  • CEO and founder of ZyDoc Medical Transcription, Retina Group of NY
  • Medical records, transcription, practice management, speech recognition, cloud platforms, security, EHRs, interoperability, diabetes, retina, pharma
  • Numerous industry presentations in medical informatics, speech recognition, NLP, and standards
  • Sold a prototype EHR to DOD, 1994; licensed medical language models to Dragon NaturallySpeaking Medical, 2000; introduced NLP data extraction from unstructured text, 2010; published NIH-Columbia Sponsored Landmark EHR Usability Study with NLP data, 2016; and #2 industry ranking in medical transcription, 2020, with #6 cloud platform
  • Former chair HOST prior to HIMSS merger, Congressional Recognition Award, co-chair World Diabetic Congress, JDRF Humanitarian Year, Gift of Sight and Anton Banko awards
  • M.D. New York Medical College
  • Vitreoretinal Surgical Fellowship at NY Presbyterian-Cornell Medical Center
  • CEWIT incubator, Stony Brook, NY
  • Can be contacted at 800-546-5633 or [email protected]

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