Preparing a Medical SummarySlide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17Preparing a Medical SummaryPreparing a Medical SummaryPreparing a Medical Summary•Rationale•Medical Records•Importance vs. Relevance•FormattingPreparing a Medical SummaryWhy?•To describe the existing medical information for a new audience•To begin interpreting medical information from a rehabilitation orientation•To provide a medical rationale for your rehabilitation or work plan for the clientPreparing a Medical SummaryMethodology: Approaching the Task•Request medical records if you haven’t already received them–Obtain release of medical information from client–Contact providers and request med records•Medical records are sent to you via mail, FedEx, courier, pick-up•Be polite and persistent in acquiring medical information from providers and sourcesPreparing a Medical SummaryMethodology: Review RecordsLook for records from•PM&R•Family/GP•Orthopedic•Psychiatry •Psychology •Neurology•Internist •Gastro •Ophthalmology•Podiatry•Pulmonary•ENT•Pediatric •Geriatric •Obstetric…any … and … AllPreparing a Medical SummaryMethodology: Review HospitalizationsLook for•Admissions/Intake Summary orAdmissions/Intake Summary or•Discharge SummaryDischarge Summaryin–Treatment records–Chart notes–Surgery Records–Inpatient Evals and TherapiesPreparing a Medical SummaryMethodology: Review DiagnosticsLook for •Summaries, Impressions, DiscussionsSummaries, Impressions, Discussions from •Consultations, Reports, CorrespondenceConsultations, Reports, Correspondenceregarding–Surgery (Operative Reports)–Radiology (Diagnostic Impressions)–Neurological (EEGs) and Neuromuscular (EMGs) function–Cardiac (ECGs/EKGs) function–Nerve conduction studies–Other diagnostic modalitiesPreparing a Medical SummaryMethodology: Review Outpt TherapiesLook for•Intake Summaries, Initial Evaluationsor•Discharge Summariesor•Recommendationsfrom–OT, PT, ST–Psychology or Counseling–Cognitive Rehabilitation–Nutrition/Dietetics–Alternative Therapies (Hyperbaric O2)Preparing a Medical SummaryMethodology: Review Outpt EvaluationsLook for • Summaries, Impressions, Discussions, and Summaries, Impressions, Discussions, and RecommendationsRecommendationsfrom–Functional Capacities Evaluations–Vocational Evaluations–Neuropsychological Evaluations–Psychiatric EvaluationsPreparing a Medical SummaryMethodology: Review ServicesLook for•Summaries, Impressions, Discussions, or Summaries, Impressions, Discussions, or RecommendationsRecommendationsfrom–Other Medical Management–Insurance–Social Work–Accommodations/Equipment–Educational records (IEPs)–Pharmacy recordsPreparing a Medical SummaryRecords: Important vs. RelevantHow to decide?All records are importantNot all data are relevantPreparing a Medical SummaryImportant•Med/psych Hx–Hx of injury/injuries–Diagnoses–Treatments–Therapies–Meds–Outcomes–Prognoses•Functional capacities-FCE•Sociodemographic info Relevant•Med/psych Hx–Intake/admission summary–Discharge summary–Diagnoses–Impressions–Recommendations–Meds•FCE–Impressions–Recommendations•Sociodemographic infoPreparing a Medical SummaryReceived•Med/Psych Hx–Pages and pages•FCE–Five to ten pages•Sociodemographics–From interview notesProduced•Med/Psych Hx and FCE–Two to five summary paragraphs•Sociodemographics–One to two summary paragraphsExpected VolumePreparing a Medical SummarySummary Rationale Records Relevance ReportPreparing a Medical SummaryFormatting•Order data in such a way that it makes sense to you•Unfold profile in logical, clear, and concise manner•Data may vary among records; present in a consistent manner within each report and across reports (be consistent in your style)Preparing a Medical SummaryFormatting• Introductory paragraph (if needed)• Choose whether to use chronology or medical specialty or other means of organization of data•Write clearly and understandably for the audience you are addressing, not yourselfPreparing a Medical SummaryReviewing Medical RecordsA Hands-On