Dos and Don’ts for Medical Records Summarization

Dos and Don’ts for Medical Records Summarization

Good summarization of records can enable you to defend yourself in a negligence lawsuit, and it can likewise keep you out of court in any case. You need to ensure that it is total, amended, and convenient. In case it's not, it could be utilized against you in a lawsuit.

 Here is list of the Dos and Don'ts you need to remember the while summarization of medical records. 

Let Us Go Through Some Dos:

•  The Most Current Information:  Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities.

• Clinically Pertinent Information: The medical record is a primary mechanism for providing continuity and communication among all practitioners involved in a patient's care.

•  Follow-Up Plans: Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response.

• Handling Conflicting Data: If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.

• Write legibly: Make document summary of patient, which is capable of being read or deciphered especially with ease.

• Medication: Mentioned a patient's refusal to allow a treatment or take a medication and also chart the time you gave a medication and the patient's response.

Let Us Go Through Some Don’ts:

• Don't alter a patient's record--this is a criminal offense.

•  Don't use shorthand or abbreviations that aren't widely accepted.

• Don't write imprecise descriptions.

• Don't to diagram for what another person stated, listened, felt, or noticed unless the information is critical. In that case, utilize quotations and characterize the comments properly.

• Don't chart care ahead of time--something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

•  Don't include the filing of incident reports or referrals to legal services.

Final Words:

Our expert team at ITCube BPO has a wealth of experience in the healthcare record management industry over a decade. We hope our advice is helpful to you. 

If you feel that you need more support with the process or you have any questions for us, please feel free to contact us on info@itcubebpo.com or you can call us on +1 (614) 434-2376

Simplified Medical Record Summary Process by ITCube BPO/KPO Solution

Simplified Medical Record Summary Process by ITCube BPO / KPO Solution

ITCube focuses on working closely with clients to document various operating processes and to determine the key performance parameters (KPI’s) that can be used for evaluation. 

ITCube Solution is dedicated to providing a wide range of services for medical records summarization.

Challenges

1. Sorting through the stack of unorganized medical records or electronic records to be able to review the case
2. Insurance company’s /law firms spend a lot of time in going through unorganized records
3. How to save time and money while becoming more efficient?

Medical Record Back Office Services/ Solutions -Overview

1. Medical records back office solutions offered by ITCube accelerates Medical Records review process.
2.  As an end result it saves time and a lot of money
3. Our solutions benefit: -

•        Medico-legal consultants

•        Attorneys

•        Case or Chart review firms

•        Insurance companies,

•        Private corporations

•        Physicians

•        Independent medical examiners

•        Social security Disability firms

       
      4.  ITCube Advantages:

•      Delivers the output of the services within the agreed TAT.

•      More than 6 years of experience with Medical Records.

•      Capable of handling high volumes of Medical Records.

•      Team of trained medical professionals and doctors available.

Medical Record Service Offerings

1-A. Records Sorting service (By Location, Date and Type of records)

1. ITCube understands the importance of organized medical records management.
2. We Sort and organize medical records by DATE - forward or reverse order for easy visualization of treatment time frame
3. We separate the Records by Type–Location Visit, Billing and Administrative pages
4. We also provide a list of all Medical Providers with #of pages
5. With records sorted by Date & Type- viewer can understand the sequence of events and quickly review the records.
6. Add on service: In case of all mixed up records, we separate the Record by Locations as well.

1-B. Indexing and Bookmarking Records

1. Systematically organized medical records with Index, hyperlinks and Bookmarks go a long way in preparing your case.
2.  ITCube uses its proprietary sorting tools to deliver Index with Hyperlinks for instant navigation to the actual pages. The Index will show chronologically arranged pages with Report types
3. Along with Index you also get bookmarks for easy navigation. The bookmarks are arranged by-
   
   •      Type of document – (Location visit, Billing & Administrative)
   •      Dates (Forward/Reverse chronology –as per your requirement)
   •      Providers and within providers arranged by dates
4. We provide a separate log for administrative pages and duplicates
5. This is an express service with fastest TAT of 1-2 days in this industry.

 

2. Medical Record Summary

1. Medical Records Summary is a premium off erring which includes all features for a quick review of Medical records.
2. This offering includes-

•      Medical Records Summarized by Medical Professionals Providers.

•      Records are Sorted and organized by DATE–forward or reverse order

•     Index is prepared with Hyperlinks to the actual pages and the summary pages. The Index will show chronologically arranged pages with Report types.

•      Bookmarks are provided which are arranged by-

                                         a. Type of document

                                         b. Dates - (Forward/Reverse chronology)

                                         c. Providers and within providers arranged by dates

•      The records are OCR’d and numbered for quick search

3. Billing Data Sorting and Summary

1. Billing records are an integral part of any Medical record
2. ITCube understands the importance of billing records and provides Billing data sorting and Summary services.
3. We arrange all the billing data by date for easy review
4. All the data are hyperlinked to the actual billing pages for quick reference

 

4. Keyword Search and Keyword Indexing Service:-

1. Sometimes for large records keyword search helps to locate critical information and speeds up the review process
2. OCR cannot take care of poorly scanned documents and hence we have medical professionals going through each page of the medical records to locate the critical words provided by you. This is Keyword Searching service provided by ITCube.
3. For quick navigation a keyword Indexing provided by ITCube which shows the # of occurrences of a particular keyword and the pages where they appear
4. Along with index, keyword bookmarks are also provided for quick navigation.
5. ITCube offers keyword search and indexing service as an add-on with its premium Medical Records Summary service

5. Location Sorting Service and Location Merging Service:-

1. Location sorting is done when we receive one set of pages where different locations are present.
2. The team goes through the pages and separates them by locations / facility.
3. Location merging is done when an earlier summarized set needs to be merged with the current set of records.
4. This can be done if the new set is received within 6 month of the earlier set.

Final Words: -

If you are interested in our service, call on +1 (614) 434-2376 or send us your queries at info@itcubebpo.com to get started. We will discuss with you all your requirements and work with you to put together a detailed scope.

ITCube provides customized and unique solutions for records management. We have a strong team of experts with over 10 years of experience in the healthcare record management industry.