![]() Gather and compile all clinical communication between the health care providers and the patient. Mention clinically-related correspondence.For instance, care during labor and the rationale for an operative delivery have to be mentioned. The medical summary should include alternatives considered, the medical judgment of the health practitioner, and the clinical basis of the decision. Note down if there was any lapse in obtaining the written recommendation of a consultant. The diagnostic and treatment rationale has to be documented to point out that another course was overlooked. ![]() Record the rationale for clinical decisions.Also, the data should corroborate evidence to sue medical practitioners if they have administered the wrong medication to the plaintiff. In a personal injury case, the medical summary should contain the particulars of the medical practitioners who gave immediate care in the ER. It is crucial to list all the health practitioners involved in the treatment of the plaintiff. Focus on clinically relevant information.It should also elaborately mention the present medical condition of the plaintiff.Įnsure that the details of the medication that induced allergic reaction or any adverse condition are mentioned in the medical summary of the plaintiff. The medical summaries should reflect the treatment and care received by the patient. Make sure that you have all the required medical records prior to writing summaries. Highlight the most recent information first.While summarizing medical records, you need to ensure that the medical records are complete, correct, and convenient. What are the Dos and Don’ts for Medical Records Summarization? What are the Dos and Don’ts for Medical Records Summarization?.
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