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Medical Record

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.  The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.

MR

Narrative Summarization of Medical Records

Medical summaries form the essence for resolution of personal injury cases, Medical malpractice or medical injury, Insurance claim.  It describes the accident, the mechanism of injury and the immediate care provided at the scene and in the emergency room, in a summarized form.  Records of hospital stay, subsequent treatment by the physicians are summarized.  Scriptyum India Pvt. Ltd. has a competent and extensively trained team of nurses and medical/paramedical staff apart from its attorneys, to attend to summarization of medical records.

The medical summarization indicates and highlights medical information which helps legal experts in identifying the case’s strengths and weaknesses. The arrangement of medical records in a chronological order assists in easy visualization of treatment timeframe.  The organization of medical records summary helps to decrease review time by 25% to 40%.  Medical Summarization provides an easy and simplified review process for legal experts.

 

Organization of Medical Records

Each hospital has its own procedures for organizing a medical record.  Most of the time, this will be done by the medical records department, also known as the Health Information Department.  Usually, the record will be organized in terms of the temporal sequence of events with the latest admission located at the front of the medical record.  After the patient is discharged from the hospital, a summary of the patient's diagnoses and treatments may be prepared by the attending physician and inserted at the front of the medical record.  This summary can be used as a guide to ensure that reports are not overlooked.  Abstracting should, however, directly be done from the actual reports in the record and not from the point of view of the attending physician. Usually, dictation occurs after the patient is discharged from the hospital, possibly from inadequate notes or an incomplete medical record.

In some facilities, a copy of the tumor registry abstract is kept in the patient's medical record. It acts as a handy summary of the history, diagnoses, and treatment.  Not only is the abstract a useful service to physicians, but it also makes them aware of the registry as a source of cancer data available in their own hospital.


Electronic sorting and Categorizing

Scriptyum India Pvt. Ltd. understands the importance of organized medical records, and hence provides high-level medical records indexing, categorizing and sorting services.  With systematic organized electronic medical records, the reviewer can quickly navigate the archives and easily review the necessary documents, greatly reducing reviewer's time spent on case evaluation.


Annotated Index of Medical Records

Indexing medical records is a vital function within any healthcare facility and needs to be managed diligently with great attention to accuracy and detail.   We offer high-quality professional indexing services to help you manage patient records and related documents in a systematic and well-organized environment. Our well-designed indexing system helps in the comprehensive management of patients’ medical data, including demographic data, treatment-related information, clinical history, medical reports, health insurance ID, insurance entitlements, and health service provider notes.

 

Hyper link

Scriptyum India Pvt. Ltd. provides easy navigation within the organized electronic medical records to save reviewer’s time.  Hyperlinked medical records are created to allow reviewers to instantly locate and access the required documents.  On demand, our hyperlink services go hand-in-hand with our Summary Services and Electronic Sorting and Categorizing of Medical Records services.


Keyword Searching

As we move into the digital world, paper medical records are typically scanned and converted to PDF files. Unfortunately, in these scanned PDF files, reviewers cannot search a critical word or easily locate specific information.

Scriptyum India Pvt. Ltd. now converts basic scanned PDF files into a Searchable PDF file format that permits effective and easily searchable options. Reviewers save significant time and instantly pinpoint all mentions of these important keywords.

Whenever needed, the reviewer simply prepares the list of keywords that are relevant to the claims. Then, using Scriptyum India Pvt. Ltd.’ Searchable PDF file, the reviewer instantly searches & locates the required information.


Identifying Missing Medical Records

Scriptyum India Pvt. Ltd. provides this service for any client where identifying and accessing all available medical records are critical.  Trained Scriptyum India Pvt. Ltd.’ staff read through the medical files in order to identify missing medical providers’ medical records and notes.


Medical Data Extraction

Solve the challenges of extracting critical medical information and common facts from large volumes of cases prior to merit review, medical-legal analysis and case preparation. We take on the tedious and time consuming medical data extraction and file organizing tasks in an extremely time and cost efficient manner. When you think about deploying your firm's resources, consider Scriptyum India Pvt. Ltd..

This specialized support is provided to assist Defense and Plaintiff Attorneys who litigate class actions, environmental & toxic torts and product liability cases.

Scriptyum India Pvt. Ltd.

#549A-1C, Maha Swetha Manor,
NSR Road, Saibaba Colony,
Coimbatore, Tamil Nadu,
India – 641 011
Tel.: +0091-422-4373764

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