Patient History: The Integral Part Of The Medical Report

PATIENT HISTORY: THE INTEGRAL PART OF THE MEDICAL REPORT

It is true 'Listen to your patient & they tell you the diagnosis’

Modern medicine practices are ethically bound to documentation of the data generated during patient’s treatment. Documenting complete information of the illness and treatment has generated enormous medical records. It can be history record/initial visit record, admission form, operative report, follow-up visit, therapy note, pharmacy note, discharge note or death report also. In all these reports, patient’s history is one of the essential element which is captured.

Patient History:

This term can be defined as the past information of the patient which is medically important gathered mainly by asking specific questions to the patient or concerned people. This has proved to be the evidence based approach in differential diagnosis. History taking and documenting is an art. History is normally collected by nurse or the treating physician every time when the patient approaches the doctor for any new complaint mainly.

History of the patient is collected under various subheading, it has its own importance in the treating the illness:

1. History of Present Illness: Current complaints, events or incidences with relevant details are the part of history of present illness. The details include description of the injury, complaints, examination, finding, investigations and treatment rendered.
2. Past Medical History: It includes significant past diseases, illness, trauma, accidents or complications the patient has suffered in the past.
3. Past Surgical History: Past surgeries with complications if any are mentioned under this heading.
4. Family History: This section includes medical history of the parents, siblings, children or blood relatives but never of spouse or in-laws.
5.  Medicine/Drug History: Current medications with dosage and medications taken in the past are listed under this heading.
6. Allergies: Any allergies to drugs, food, animal, dust, pollen or seasonal are mentioned with effects seen on the patient.
7. Social History: This section includes patient’s habits like smoking, drinking, drug abuse, it also includes information on marital status, occupation, pets, habits and accommodation.
8. Systemic Assessment: Under this subheading all the other complaints related to body systems are included.
9. Psychiatric History: This is frequently lengthy and in depth history of patient’s emotional status.
10. Immunization History: Immunizations from birth and yearly immunization dates are mentioned under this history.
11. Diagnostic Studies: The review of the various diagnostic studies carried out for above mentioned problems are mentioned under this heading.

‘It is said that a good history is one which reveals the patient’s ideas, concerns and expectations as well as any accompanying diagnosis’.

Inhibition in collecting the good and relevant medical history could be due to inability of the patient to communicate, improper doctor-patient relationship, unwillingness of the patient to disclose certain information.

Computer Assisted History Taking:

Computer technology started in 1960. It allows easy collection and portability of the medical data saving money and paper- known as electronic medical records.

Advantages of The Medical History in Medical Data Processing:

Accurate medical history is an advantage for any care giver while treating the patient. There are many advantages of accurate history data in various other aspects related to medical field:

1. Insurance: In settling the claim, medical history proves very helpful. Assessing the history from medical data decides the flow of the claim.
2. Investigational Aspect: Patient history in medical records plays and key role in investigational aspects of the legal and criminal cases.
3. Recruitments: History of the patient is an integral part of the documents required for recruitment.
4. Pharmacogenomics: To study genome in drug response patient’s history is a vital data that has been gattered. It is studied to better understand the biology behind diseases and drug response phenotypes.

Conclusion:

ITCube understands the widely spread importance of medical history. Handling all types of medical records and accurately correlating the medical history and summarizing it, which enables the review of those records easy and less time consuming. ITCube caters this services to various litigation firms and TPAs, which indeed helped them to focus more on the core business as we provide the very precise, accurate and handy summaries saving their time to review the documents.

To know more about ITCube services you can mail us on info@itcubebpo.com or you can call us on +1 (614) 434-2376.

Healthcare Industry - Benefited By Medical Summarization

Healthcare Industry - Benefited By Medical Summarization

Healthcare industry today deals with enormous health data in the form of health records including treatment and diagnostic records, nurses’ records, graphs, assessment sheets, history records and many more. There are electronic records, handwritten records, pictures and x-rays which can be termed under medical records.

This huge data is required for patient’s treatment, insurance processing as well as in drug development and research industry. The data present on the records many a times is in short forms, symbols, scattered and incomprehensible and needs a structured, simplified and accurate extract, which facilitates fast claim processing, correct and adjuvant treatment to the patient. This is well achieved by various ways including medical data summarization.

What is Medical Data Summarization?

This is a process of comprehension of medical information from medical records. The medical record reorganization goes hand in hand with summarization process. The medical data is arranged based on date of the visit, location where the document is generated and the disease.

Summarization provides extract from the tedious event flow sheets and coverts worst handwritten and scribbled notes into a meaningful document also gathers scattered medical information for a particular illness of the patient into a well-organized and rational document.

  

How the Healthcare Industry is Benefited by Medical Summarization?

 

Medical records summarization provides data in various dimensions based on the end-user.  Medical providers as a user can always locate a particular date for treatment or a particular symptom easily instead of searching in the pile of documents. This is achieved by bookmarking and hyperlinking of the medical records. Medical history is easily accessible to the physicians, which reduces the time in scanning same information on every document.

The time spent to review the bundles of records is drastically reduced for the attorney or claim adjusters. Technological involvement in this process adds to the benefits like keyword searching, which helps to locate key features in the medical documents.

For researchers, it provides abstract based on a particular aspect of the research. This reduces their paperwork drastically.

Medical data transfer and archival has been easy with medical records reorganization and it ensures the data integrity and safety. Medical record summarization and reorganization indeed has proved to be a boon to the medical data reviewer.

To know more about medical record summarization and reorganization, you can mail us on info@itcubebpo.com or you can call us on +1 (614) 434-2376.