How to Summarize Medical Records [Fast & Easy]

Creating medical records or documents is nobody's favorite job, but no matter how much one dreads documenting all these things, it's an important part of medico-legal cases. But writing all the medical information onto paper isn't going to cut it. 

You'll need an organized system to summarize only the important information from the lengthy medical record in any medico-legal case. While medical record summaries take up-front time to build, they are worth the investment. 

After a week of talking to medical experts and people who often create medical records, I decided to create this guide. Here, I'll show you how to summarize medical records so you can get most of your tasks done faster and better. 

What is a Medical Record? 

The medical record is an important part of medical records summarizer jobs that combine both medical and legal documents. It typically includes information about a patient's health, family history, and even medical history. Often, healthcare professionals use these records to improve the care given to patients.  

Even legal cases (For example, personal injury law) can benefit from the medical records — where it's important to take the medical history of the patient into account. Remember, no two medical records have the same structure, format, or summary — therefore, you must take time to analyze the document and then create a brief version. 

Medical record summaries of the patients

How to Summarize a Medical Record? 

Let's be real: summarizing a medical record isn't as simple as summarizing a simple document. I've seen my share of bad summaries and have created many (I hope!) good medical record summaries. Here, I'll share how to summarize medical records that stand the test of time — and that people can actually use. 

Start with the Recent Information 

Medical documents are complex — and you'll quickly find yourself flooded with a lot of information. The best way to summarize these documents without feeling overwhelmed is by highlighting the most recent information first. The summary you write should reflect the care and treatment that was received by the patient — and their current medical condition. 

Focus on Clinical Data

The next important thing is to focus on the clinical data and the list of health professionals. Here, you can also incorporate the data about the medical practitioners who gave immediate care to the patient. 

Use a Grid and Narrative 

Nobody loves to read a cluttered summary — it's important to follow a grid and narrative structure while performing medical records summarizer jobs

Only a sorted table in the spreadsheet is a great way to organize a medical record summary — with appropriate columns for date, summary, bills, and provider. Once the grid is ready, write a quick narrative either as a memo/email or as one part of a letter. 

Always Add Key Findings 

Generally, medical reports like CT scans, MRIs, X-rays, or surgical tests such as biopsies come with descriptive paragraphs and even an important part titled 'Findings.' These key findings are what you'll need to properly mention in the medical record summary. 

Review and Revise 

Medical professionals use a lot of complicated terms that aren't easy to understand. Once you've summarized the medical record, review and revise the information to avoid any mistakes or loopholes. Sometimes, I prefer to read the summary aloud, cross-check the points, and erase the fluff to make sure it's short and informative. 

Read and revise the medical summaries

Example of a Medical Record Summary 

A medical record summary is a concise summary in which you introduce the patient and a few key points about their health. It should be short enough that anyone can scan within a few minutes. If it's getting too long, the core idea behind the summary isn't fulfilled. Here, I'll show you one medical record summary of a patient named Hamlet. 

Example: 

You can start the medical record summary with some important medical details of the patient that typically include the patient name, date of birth, and medical record number. 

Patient Name: Hamlet Patrick 

Date of Birth: 01/12/1886

Medical Record: MFTY12345

Next up, you'll need to list the medical, surgical, social, and family history, typically available in medical record software. Depending on the type of medical record you're summarizing, it can be either a few paragraphs long or a few pages long. 

Medical History: Hamlet was diagnosed with hypertension in 2010 and was managed with medication (insert the name of the medicine). 

Social History: The patient is a non-smoker, occasionally uses alcohol, and lives a sedentary lifestyle. 

At the end of the medical record summary, you can write immunizations, medications, and even recent laboratory results (within the last few months). 

Tips for Summarizing a Medical Records

Everyone knows the feeling of writing lengthy medical papers and then summarizing them. As the word 'research' comes, we all start to sweat. I'll be honest: following some tips has helped me save more time than I can count. Here are my top tips that'll help you summarize documents faster. 

Understand the Purpose

The first tip is to understand what's the purpose of writing or summarizing the medical record. For this, I keep the brief of the medical record handy while summarizing the long document. The brief includes a short summary of the record's objective, medical notes about tone and formatting, and any other important information required to summarize the medical record. 

Write in Easy Language 

The next thing I take into account (and you should, too) is the language you use while summarizing. You want to be sure the content resonates with the readers, even if they do not belong to the medical field. For example, use simple language to explain medical-related terms that might seem hard to the readers. 

Stick to the Facts

While condensing the long medical documents into a few paragraphs, you might be tempted to give your opinions — but don't. Since medical records are also used for medico-legal purposes, it's best to stick to the facts, figures, and supporting data. 

Stick to the facts while summarizing the medical records

Use AI Medical Record Summarizer 

We humans have a bad habit of complicating things unnecessarily. Thankfully, an AI medical record summarizer tool can help you save time and uncomplicate things. One such powerful tool that can record, transcribe, and summarize media files is Notta Web App

It's pretty to use (and relatively more accurate than other AI summarizers I tested): just upload the pre-recorded medical documents and hit the transcribe button to generate the transcript. With the Notta AI Summary Generator, you can then summarize the transcript into an overview, key chapters, and action items. 

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FAQs 

What Should be Included in a Complete Medical Record? 

A complete medical record is a complex document that includes:

  • patient's medical history;

  • patient demographics;

  • treatment and diagnosis;

  • list of the lab test results;

  • history of previous hospitalization and surgeries;

  • and detailed data about medical insurance and billing. 

Many medical records pay extra attention to the history of illnesses and allergies to strings, medicines, foods, and other substances. 

What is Patient Record Summarization? 

A patient record summarization is the process of extracting only the key points from the extensive medical record. It's generally a brief version of the record written in an easy-to-understand language. This medical record summary gives a clear understanding of a patient's health to the healthcare professional or medico-legal lawyer (if that's what you need). 

Key Takeaways 

Everyone's need for a medical record summary looks different, and finding the right balance to create short yet informative summaries takes time. But is it easy? Honestly, it's not. Many things can slip through the cracks, especially if you haven't worked with medical documents before. 

Thankfully, AI note-taking and medical record summarizers like Notta can help you answer the question of how to summarize medical records. With the Notta App, you can even transcribe complex medical audio recordings and videos — and then summarize the transcript into short texts. This AI tool can help you work with medical information faster and carefully extract the key points.

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