What Makes Medical Record Review Complicated?

Medical Record Review

Though the medical records are generated as a testimony for the treatment given to the patient, the data in the records remains challenge to reviewer. Is it the data or the medical terms or is it anything else that is a big dare, let’s find out? When a report says ‘the patient has fever and was treated with anti-fever medications’, the data becomes simple. But when the data turns like, ‘The patient feels febrile with temperature 99.8 with no other signs of infection, chest x-ray and complete blood count showed no evidence of any abnormality, diagnosed with PUO and was treated with antipyretics’. It takes much longer time to assimilate the information and may require searching few word meanings and a few full forms to find out the diagnosis. This is a great time investment. If this data is written as ‘The patient had fever with e 99.8 with all tests normal. Diagnosis is pyrexia of unknown origin and was treated with antipyretic medications’. It becomes much simpler.

This shows that the medical terms, complex medical procedures steps and data presentation in short forms or in case of some reports like flow sheets or assessment sheets constantly updating data complicate the process of data assessment.

Extracting relevant information from negative observations, normal status is difficult unless it is marked and highlighted with ‘bold’. Various medical terms are used to in physical assessment and out of those terms 80% of the terms turn out to be insignificant. There are various terms used like EOMI, RRR, GCS and DTRs in physical examination. These terms need to be understood to interpret the observations by the physician.

Many reports are short and simple to understand, but reports like radiology or pathology can turn out tricky. When a radiograph or CT scan or MRI of the spine are considered, the observations listed are detailed but the final impression may be a short termed coined for all the symptoms and one may wonder why the diagnostic terms used in observation are not considered in the impression. There are a few reports like flow sheets or assessment sheets, which show observations taken every few hours. To understand how much were the fluctuations in the readings or what were the abnormalities noted in the tracking machines like heart rhythm monitor, oxygen saturation monitor etc, it takes thorough review of complete data. It becomes hectic to extract only abnormalities in the above readings during a particular day monitoring from a huge pile of records.

Let’s Make The Life Simpler Using Medical Records Summarization:

Though the complexities are more while one reviews the medical records, but there is always a solution to reduce efforts while dealing with such situations. What if all the medical records are gathered and arranged systematically, and what if each of the record has its own extract presented in a structured pattern. The records getting summarized into following formal will provide a better presentation of the patient’s visit or the medical record:

  • Complaints systematically arranged with the events during the complaint.
  • Previous treatments, histories including medical, surgical, family, a list on current medications and allergies.
  • Physician’s positive observations including physical assessment, supportive diagnostic interpretations.
  • Diagnosis of the current situation
  • Treatment mentioned in systematic way to understand the medication status, any other instructions, surgeries planned, follow-ups and referrals.

Medical record summarization has proved to be the very supportive tool to help review piles of medical records and save time. ITCube BPM provides well-designed summaries with multiple other excellent features to make the life of medical data reviewer easy.

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