Medical language and non-medico person! Ohh! This is not the right combination. Greek and latin words source and prefixes and suffixes make medical word almost illegible for a lay person. On top of that if any medical document is handwritten with all abbreviations used, it is near to impossible for any non-medico person to comprehend the data out of medical report. It must be very difficult for any attorney or insurance verifier to read medical report.
What are the challenges faced while reviewing medical records?
- The physicians or nursing staff is so busy in patient’s care and therefore it may not be a good handwriting on the medical record, which is legible by any outsider. The abbreviations and pointers used and may be diagrams scribbled may not be comprehensible. Person reading these documents should know various full forms of abbreviations and its appropriate options fitting to the context. For example, if the document shows ROM-intact…One must check the relevance with orthopedic or Obstetrics. It would be expanded as range of motion is intact in orthopedic and for obstetrics it would be rupture of membrane status-negative. So understanding the right relevance is an important factor.
- Handwritten document may confuse us with CNS-negative or C&S negative. These words are similar except for N and & referring to way far systems of central nervous system or laboratory testing. It has meaning of central nervous system assessment negative in neurology section and culture and sensitivity negative showing lab test negative. One needs to interpret correct words out of handwritten data on medical records.
- There could be soundalike word misspelled incorrectly in the original document which may get skipped during review or may be again wrongly interpreted. Best example is bolus and bullous. One small spelling change makes a lot of difference, where bolus is used when a large quantity of medication is administered orally and bullous is related to bullae.
- A small dot also makes a change in the meaning, for example OD and o.d. It changes from right eye to medication dose once daily with single sign of dot.
- There are many signs like triangle, arrows, check mark which imparts specific meaning when it is related to context. Understanding of such signs are also very important.
There are a many more such scenarios one need to face while reviewing the medical documents and might end up in misinterpreting the context. Here the team of experts can help you who can understand this ‘symbolic language’ and convert it into the readable and reviewable format for you.
Summarizer does it all:
A summarizer reads through the context and converts this complex puzzle into simple and short summary. He is a person who had in-depth knowledge of medical language, anatomy, physiology, pathology, who understands pharmacology. He is an expert in analyzing the whole context and collect only relevant information from the record and convert into a precise and concise extract, which is easy to review any time and every time. During this process he understands all the abbreviations and symbols, relates correct medical terminologies to the current medical condition, corrects the spelling confusion if any and generates a summary.
Medical summarizer is a boon to any processes required to handle medical documents. They not only give a well-crafted readymade summary of medical records but also help in reducing the review and analysis time which has a great impact on cost.