Dos and Don’ts for Medical Records Summarization

1
Dos and Donts for Medical Records Summarization
2
Medical Records Summarization

• Medical records summarization is a process that
  simplifies the intricate and tedious task of
  bifurcating, chronological arrangement and
  preparing synopsis of the numerous medical
  records..
• Medical record summarization service gives a
  summary of patient's medical records in a healthy
  straightforward frame.
• Good summarization of records can enable you to
  defend yourself in a negligence lawsuit, and it
  can likewise keep you out of court in any case.
  You need to ensure that it is total, amended, and
  convenient. In case it's not, it could be
  utilized against you in a lawsuit.

3
Here is the list of DOs DONTs you need to
remember while summarization of medical records.
4
Let Us Go Through Some Dos -
5
Dos -

• The Most Current Information Check that you
  have the correct chart before you begin writing.
  Make sure your documentation reflects the nursing
  process and your professional capabilities.
• Clinically Pertinent Information The medical
  record is a primary mechanism for providing
  continuity and communication among all
  practitioners involved in a patient's care.
• Follow-Up Plans Chart precautions or preventive
  measures used, such as bed rails. Record each
  phone call to a physician, including the exact
  time, message, and response.

6
Dos -

• Handling Conflicting Data If you remember an
  important point after you've completed your
  documentation, chart the information with a
  notation that it's a "late entry." Include the
  date and time of the late entry. Document often
  enough to tell the whole story.
• Write legibly Make document summary of patient,
  which is capable of being read or deciphered
  especially with ease.
• Medication Mentioned a patient's refusal to
  allow a treatment or take a medication and also
  chart the time you gave a medication and the
  patient's response.

7
Let Us Go Through Some Donts -
8
Donts -

• Don't alter a patient's record--this is a
  criminal offense.
• Don't use shorthand or abbreviations that aren't
  widely accepted.
• Don't write imprecise descriptions.
• Don't to diagram for what another person stated,
  listened, or noticed unless the information is
  critical.
• Don't chart care ahead of time--something may
  happen and you may be unable to actually give the
  care you've charted. Charting care that you
  haven't done is considered fraud.
• Don't include the filing of incident reports or
  referrals to legal services.

9
Contact Us -
ITCube BPO Solution, Email- info_at_itcubebpo.com
Phone- 1 [phone] 10999 Reed Hartman
Highway, Suite 134, Cincinnati, Ohio - 45242,
USA
www.itcubebpo.com
10
Thank You..!