The Anatomy of a Medical Record Summary

by | Published on Feb 12, 2021 | Medical Record Review

Medical record summary and medical chart review is an essential service to both legal and healthcare industries. This involves analyzing voluminous medical charts and categorizing them based on service providers and content, or any other preferred category. The medical summary prepared is useful in litigation, healthcare and insurance claim processing. This service is provided by medical claims review companies where trained medical professionals review the medical records and interpret the data contained therein. Now, the latest advanced technology is used to ensure easy access to the medical data required.

Summarizing medical records requires professional expertise because

  • There is complex medical language involved and a non-medical person may not be able to interpret it correctly.
  • Another major concern with medical records is that some of these may be handwritten with a number of medical abbreviations.
  • Attorneys and their legal teams or insurers that need medical data related to a patient/claim will not be able to understand these abbreviations or medical terms pertaining to different medical specialties.
  • There may be similar-sounding words that could be misunderstood and wrongly interpreted. Even minor spelling changes could create serious issues.

A specialized medical claims review company would have professional summarizers who are knowledgeable in medical terminology, anatomy, pathology, physiology, pharmacology and related aspects. They also have a clear understanding of all medical abbreviations and symbols, will correct any spelling mistakes present, and prepare an accurate summary. They will review the records and extract only the relevant information from the medical chart.

What does the medical summary preparation involve?

Once all the required medical records are received via secure file transfer,

  • Analyzing and Categorizing: In this step, each piece of information is analyzed and categorized based on medical history, complaint, observations, diagnosis, prescribed treatments and so on. This will help visualize the treatment time frame easily.
  • Organizing the Medical Records: The medical records are sorted and organized and the summary created by date, either forward or reverse, to facilitate easy view of the treatment time frame.
  • Indexing the Records: This involves creating an index of providers, with report types placed chronologically by date in forward or reverse order.
  • Hyperlinking: Hyperlinks are provided to the source records from the index and summary page. This facilitates navigation.
  • Delivery of the Records: The final medical summary report is created in the required format, such as Word or PDF, as the client prefers.

The medical case summary prepared can be comprehensive or a simple index summary.

  • The former provides a detailed view of the patient’s medical records so that all relevant information is clearly available. This type of summary is very useful for personal injury, toxic tort, and medical malpractice cases.
  • The latter type gives a general view of the medical records. This is a suitable option when you want the records sorted and indexed so that they are easily accessible and available for ready reference. Also, this type of summary is the ideal choice for claim cases with shorter deadlines.

As seen above, summarizing medical records is not an easy task and demands professionalism. When done professionally by a company providing medical record review for insurance companies, the summary will ideally meet the specific purpose of the end user, whether plaintiff or defense attorney, handling claim settlement cases. A trained and experienced medical record summarizer ensures that the summary is simple, precise and brief so that the end user can easily understand the crucial medical facts.

Listen to our podcast on Anatomy Of A Medical Record Summary

Discover our medical record review solutions and partner with us for your next case.

Related Posts

Optimal Techniques for Medical Record Review

Optimal Techniques for Medical Record Review

In the medico-legal sector, accurate medical record review processes are crucial, not only for providers to ensure optimal patient care and regulatory compliance, but also for attorneys and insurance companies. By understanding the complete medical picture of the...