ED Records-Complexities to Understand

Medical data is stored in the form of various records like History and Physical, Consultation or Emergency Department Report. Let’s understand what an emergency department report looks like and what makes it complicated.

Emergency Department Report is generated when a patient visits ER for acute situations like a minor injury, an accident, stomach aches, headaches, or maybe some bump. To understand the complaint better, one needs to understand the component of the complaint like pain intensity, site of the pain initiation, pain radiation to other sites, pain characteristics like pins and needles, stabbing, burning, etc. Documenting loss of consciousness in injury includes the duration of loss of consciousness, duration between actual impact and LOC, and associated symptoms to understand the extent of brain injury. Even for the smallest complaint of cough and cold, it is necessary to look for characteristics of cough including color, the smell of cough, frequency, presence of blood, consistency, and associated shortness of breath if any. So, finding out such information from initial conversations with the patient, nurse’s observations, and doctor’s examination requires to focus on positive and negative remarks, a complete understanding of medical terminology, and understanding on what might be observed in the physical examination when the patient has a particular complaint. Medical record summarizationis a well-trusted solution provided for complex data review. A virtual team working as a litigation support team converts variegated medical information into systematically arranged medical data ready to be reviewed. What makes medical records complicated?

There is data available under the title history. It can be past medical history, surgery history, social history, family history, gynecological history, psych history, previous hospitalization history, and more. This information is very important while understanding the patient’s condition, defining the diagnosis and planning treatment plan for the patient. Past medical history and surgical history provides background to the patient’s health. Family history from parents, siblings, children or relatives give directions for diagnosis. It is very significant when information regarding patient’s smoking status, drug abuse, employment pattern, social and family environment to find out impact in the patient’s current medical scenario. Adding data for allergies if the patient is having is one of the key factors we are extracting from the report.

It’s not only the complaint that makes it complicated, but the observations noted from time to time during the course of treatment in Emergency Department create a pile of information. These include multiple readings of the blood pressure, pulse, respiratory rate, oxygen level, and scores mentioning the health of the patient like Glasgow coma score. If the patient’s condition is changing constantly, notifying the changes appropriately and presenting the worsening condition or recovering condition remains a challenge. Need to find other tests carried out on the patient to support diagnosis like Tinel’s test or Phalen’s test and need to understand on which part of the body the tests are carried out and which side of the body looks affected. One must also comprehend positive findings out of multiple values getting generated during orthopedic testing and eye examination.

There are other factors involved in the Emergency department visit like various lab tests carried out on the patient, diagnostic tests performed on the patient. There are visits of other specialty physicians for consultation and their observation and treatment prescriptions are also part of medical records for Emergency Department for the same date. Collecting their observations and recommendations to summary is necessary to make the complete summary of the ED visits. Diagnostic reports provide details of observations and infer about it. Extracting positive observations and inference is a very important aspect of gathering all related data.

Treatment given to the patient is not only in the form of medications but also includes some procedures done or planned, some therapies planned to include physical therapy or occupational therapy, and details on frequency and exercises planned about the therapies. There might be recommendations on immunization and lifestyle changes. Devices or support systems like home health are recommended. There are various instructions provided on bathing, diet, dressing changes if any, driving, dealing with medication side effects, follow-ups, and further recommendations for worsening symptoms. Medications also to be mentioned appropriately by mentioning details on continued, discontinued medications, mentioning dosage changes, frequency changes, and mentioning medication that is on hold. There also needs to mention the medications given during the ED course including normal saline, dextrose, pain killers, or any antibiotics. Need to mention if the work notes or school note is given with dates and appropriate work restrictions and activity restrictions.

This was one example we discussed of the Emergency Department Report. There are more than 100 different types of reports that need such a deep understanding of what data to be focused and to be extracted to make sure that the final extract of the ED visit has all the details which justify the ED visit and further follow-up treatments. The complexity of the data increases with the variety of data and interdependency of that data and to make it an integral extract knowing what to extract, where to extract from and medical terminology remains very important.

Partnering with a team of professional experts who have an understanding of reports, medical knowledge, data patterns and have a structured format to present the extracted data to help understand non -medical people requiring this information for their activities like medico-legal cases or claim settlement can not only benefit them in getting their work done faster but also help them reduce the cost end effort spent in reviewing such documents.

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