Just collecting main data points from medical records is not enough, the extract should be integral and easy to navigate through. Integral can be a subjective term. Let's understand what is mean by integral medical extract means and how to have it handy for use?
Around 200 million claims get denied per year in the USA. The main reasons listed for denial and rejection include medical data errors and claimed filing was delayed. This is mainly due to insufficient data gathering from the existing medical records. It is rightly said that “Poor records mean poor defense; no records mean no defense” So evidence in terms of medical information of the patient’s treatment remains a crucial point. Medical records turned into a structured brief summary will not only reduce the efforts to review enormous medical pages but will save time. Medical summarization services provide a bundle of advantages making sure that integral data is readily available, handy for review.
What is Integral data?
When the medical summaries are to be called integral? It is a tricky question and may have subjective answers. But what exactly an integral means that the data which is present in the medical records which is necessary and represent the condition of the patient as well as treatment of the patient correctly is the integral data. That includes medical and non-medical adjectives used to describe any symptoms. For example ‘severe abdominal pain’, ‘watery diarrhea’, ‘left lower quadrant pain’ or simply ‘mild tenderness over the dorsal aspect of the cervical spine”. These words including mild, severe, watery, left lower, etc. are adjectives and they add to the information about the patient’s condition, including direction, location, severity, consistency, etc. Missing these words will not create an exact picture of the patient’s complaint. Similarly, a slight change in the observations needs to be mentioned. For example, ‘he is now having yellowish phlegm’, ‘pitting edema is now increased from 1+ to 2+’, ‘bilirubin level is up from 1.2 to 2’. For a normal eye, these value changes see very negligible, but these are significant in terms of worsening of the patient’s condition. Missing these values also will affect the data. There are minor changes made in the treatment like ‘Lasix has increased to 10 mg’, ‘EMS is planned for the next PT visit’, ‘shifted to puree diet from semisolid’. These treatments are basically reflections of the patient’s condition and missing those details can create incomplete data to review.
There are multiple factors that can be missed like scores of the tests carried out, patient’s verbatim regarding social environment around, like an abusive partner, stressful life, overwhelming incidences affecting the patient and should be considered during treatment and for the claim purposes. There might be mention of family health and illness, social habits, recent travels, past surgical complications, allergies, non-compliant behavior, mention of predisposing factors. Mentioning all these makes the summary perfect.
The most important part is the summary should be capturing all the basic details of the complaint, doctor’s observations, and treatments perfectly. It is very necessary to capture injury location, mechanism of injury, symptoms post-injury, symptoms preinjury, causes, loss of consciousness, vitals, pain characteristics, duration, pain site, changes in symptoms since onset, all the tests carried out by the doctor including diagnostic and lab tests, detailed treatment provided including instructions, suggestions, advice, diet corrections, exercise given, follow-ups and referrals too. Currently, these may look like small bullet points separated by a comma, but when data extraction is done extracting these may require scanning through all pages.
To qualify as an integral summary, the extract should not miss any data point relevant to the patient’s condition, no symptom, sign, observation, or treatment point is omitted.
What is handy?
When the medical records are so large in number, extraction of the data could mean a clumsy summary, which is difficult to go through though it has all the necessary data. But if the data is well structured, well-formatted and chronologically arranged, then?
Date-wise summarization of the medical records, data categorized in the complaint, observation, diagnosis, and treatment, a summary with a date is arranged chronologically to create a sequence in treatment events and these are hyperlinked to the original medical records.
This qualifies for a handy summary providing neatly arranged extracts.
ITCube BPM is providing these services for more than a decade to various layers and claim executives. A virtual team of experts does all the work and provides a ready-to-analyze summary with organized medical records saving time.
