- The medical records are organized by categories like office records, progress notes, consultation, diagnostic studies, discharge summary, etc.
- The medical records are organized by category in chronological or reverse chronological manner
- Specific bate numbers on each record ticket are placed
- Medical records are tabulated, indexed and bullets, numbering and multi-level numbering is used.
- The records are reviewed by quality experts who judge the accuracy, compliance and completeness along with highlighting the errors.
- A record summary binder is provided that contains a table of contents and the summaries derived from all the medical records. The summary binder can also be offered provider wise or as per the date of the service.
W
in Infosoft is fully capable of organizing and summarizing medical records that are essential to your case. The work is handled by experienced professionals who work under the guidance of medical professionals. People often get confused about the differences between the medical organization and medical summarization process. We are trying to explain the same over here for your benefit.
Organization Process:
Summarization Process:
In this process the medical record review is correlated with the allegations of the plaintiff’s complaint. Special attention is paid to medical conditions that were pre-existing and the contributing factors.
The summary of medical records is prepared by focusing on below-mentioned specific areas:
- History of present illness
- Past Medical History
- Social History
- Medication
- Physical Examination
- Diagnosis
- Treatment Plan
- Recommendations
The summaries can be prepared in the following forms:
- Comprehensive Summary
- Narrative Medical Summary
- Annotated Index Summary
- Medical Chronology & Timelines
- The applicable treatment and symptoms are flagged
- Footnotes are created to define medical terms that are uncommon
- Charts and timelines are created to highlight the treatment attained from pertinent periods of care
- Missing records and bills are spotted
- A medical chart is prepared that shows relevant and irrelevant charges levied by medical providers and facilities
All the medical records can be scanned, indexed bookmarked and hyperlinked to all the summaries upon client requests.
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