5 Points That a Company Should Cover in its Medical Records Review Services
A detailed, comprehensive, and well-organized medical record is essential for a patient to ensure the proper treatment. The associated companies provide medical records review services to identify the missing gaps and bridge the same with accurate documentation for the utmost safety and proper treatment of the patients.
Since people see the medical records as an accurate representation of the condition, it becomes mandatory to have a proper audit of the report. Here are the five major components that a company should cover while providing medical records review services:
1. Treatment History
Any treatment begins from the report. The patient may or may not have any prior disease (either cured or not). The report must provide precise information about the same. The history of illness staples the details like physical examination, medical allergies, and much more.
2. Progress Notes
These notes include ups and down in the patient’s wellness charts. The medical records review services observe the mental and physical conditions of the patients along with their food intake. There is also a need to notice the vital signs at certain intervals.
3. Nursing Notes
These notes are somehow separate from the physician’s documentation. Here, the medical records review services evaluate the patient’s assessment through the nursing staff’s perceptions. This enlists the processes, treatments, assessments, and other relevant details.
4. Medication List
As the name suggests, the medication list is a collection of treatments, prescription, and non-prescription medications. The review services also take care of the methods of intake, schedules, and dosages, etc.
5. Confidentiality
The confidentiality of records matters a lot with medical records review services. It is an essential responsibility of the service provider to develop a secure environment for the reports and protect them from privacy breaches.
When looking for an ideal company to offer medical records review services, you will find Totalmed Transcription to be ideal. You can confide on it owing to several reasons:
- The chronological arrangement of medical records
- Apparent timeline and comprehensive medical journey
- Identification of gaps and inconsistencies
- Accurate interpretation and transcription
- Summarized case history
- Sorting and indexing of records
To conclude, case report creation and review service must follow the work ethic. You must therefore assign the task to the most trusted medical record review company for supreme vitality advantages. Totalmed transcription is the best to consider in this regard.
