Leave Medical Data Management To MDS

Medical reports, medical records, medical data! These words are irrefutable for insurance companies and medical lawyers. Every day insurance companies and lawyers are struggling with an enormous data scattered in a pile of documents. Searching relevant data for review is a big task. Going through different report types from complex records like anesthesia reports, operative reports, assessment sheets and flow sheets to simple records like prescriptions or nurse’s orders requires a lot of time and complete focus to capture minute details of patient’s treatment. These records range from hundred to thousand pages with vital data on every corner of the document. The data is also not in a legible format. It many a times has illegible tag due to bad handwriting or poor scanning. The information in mostly mentioned with medical abbreviations and jargons. How anyone can expect lawyers and claim representatives to convert this big data into short summaries? Insane, isn’t it?

What if these pages get arranged in the systematic way showing the medical events and treatment journey in a systematic way? How about having a meaningful data captured and represented in meaningful way where review time gets reduced drastically? Is this possible?

Of course, this is very much possible and in practice! Medical data summarization is the answer!

Medical Data Summary:

Arranging medical records date wise, according to the report time is one of the advantages of medical data summarization. Searching missing pages and arranging it to show complete report, arranging the reports based on report types if required is done during MDS. Data on every page read and interpreted rightly by medical expert and converted into a short summary which shows the complete picture of the patient’s visit on a particular day or hospitalization is main feature of summarization process.

There Are More Advantages Like:

• Better patient care.
• Fast analysis of the huge medical data.
• Time saved during accessing the medical information.
• Less paperwork and better archival options.
• Increased quality of the source data due to multiple reviews.
• Less man-hours and cost effective.

Medical data is categorized into history, current complaints, treatment, observations and impression and presented in a very systematic manner with bookmarking and hyperlinking is nothing but the seamless medical record review for attorney or claim representative.

Rehabilitation- Key For Healthier Life

Rehabilitation- Key For Healthier Life

Rehabilitation means returning someone to the normal condition physically or mentally or by both. In healthcare this word has its own importance to treat patients. Patients with physical injury, mental illness both can be treated successfully and can be bought to the normal life with Rehabilitation along with other medicinal treatments. Neuropsychological therapy, occupational therapy, physical therapy and speech and language therapy are some of the examples of the rehabilitation services provided to the patient.

Surgical interventions or other procedures helps the patient to get rid of the basic cause of the disease, but regaining the strength and normal functional capacity is achieved with these rehabilitation services.  The treatment is given to make the patient capable of living unassisted. There can be Inpatient hospital treatment, outpatient treatment or maintenance treatment. All the documents generated for treatment form the integral part of the medical records of that patient.

Types of Rehabilitation Services:

     

• Physical Therapy: Therapy is given for patients with functional limitations, disabilities and altered body posture affecting daily functions. Treatment includes various types of physical exercises, gait training, balance training, strength and range of motion restoring exercises. Modalities like moist heat, paraffin bath, electrotherapy or hydrotherapy are also a part of physical therapy.

• Occupational Therapy: To enhance a person's ability to regain functional skills needed to perform daily activities. Therapies are mostly based on endurance training, cognitive and perceptual training, and they help injured people to regain skills. Various aspects of the patient are being taken care like activities of daily living, education, work, leisure, resting time and social participation.

• Speech and Language Therapy: Speech, language and cognitive impairment of the individual are corrected using this therapy. Voice and swallowing problems are also assessed. This is useful for the patients with autism, developmental delay, hearing loss, cranial nerve damage, ADHD and language impairment.

Rehabilitation Report:

The number and frequency treatment visits is based on the type of disease or illness to be cured. The initial intake report has detailed information about the deficit, including but not limited to strength, range of motion, impairments. The treatment schedule is decided after this. Treatment plan is always mentioned in every visit under plan of care. The patient is evaluated based on the previous observation and current tolerance level. The short term and long term goals for each therapy are decided at the beginning of the therapy and are followed for achievement. In the final discharge visit assessment is done for goal achievement and overall improvement in the patient’s status.

Conclusion:

A well-prepared medical record management saves time by organizing medical records in a concise chronological manner facilitating easy assimilation. To know more about EHR or medical record summarization, you can mail us on info@itcubebpo.com or you can call us on +1 (614) 434-2376.

  

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.

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.