Medical Data Entry – 10 Types of Medical Reports That You Can Outsource!

Medical Data Entry 10 Types of Medical Reports That You Can Outsource!

The medical and health care industry is growing by leaps and bounds! Obviously so, the amount of data and information that needs to be handled and processed each day is enormous. And more often than not, medical and health care establishments don't have time to handle this information in the wake of more serious issues they need to address. This is where Medical Data Entry Services come into play. It helps empty space in doctor's filling cabinets and store the patient record in digital format.

Outsourcing Medical Data Entry Work

By outsourcing the data entry tasks of medical reports, these establishments can focus on more important concerns like treating patients and researching new medicines while the service providers take care of the peripheral tasks and provide them with efficient data to back up on.

People interact with health care units in a number of ways be it for regular health check-ups, any specific health issue, emergencies, specialist referrals or surgeries. Once a patient visits a doctor, a detailed record of the entire process needs to be maintained. In addition to being a statutory requirement, it helps the doctor keep record of the treatment process and monitor the progress. Moreover, it provides proof in case of litigation and can be used for further billing and reimbursement.

This is why all the data needs to be recorded and maintained very carefully. And medical data entry services do just this! Clients supply providers with raw information that is entered efficiently into the specified database or CRM systems. The only problem with this kind of data entry work could be the illegible handwriting of the prescribing doctor and to overcome the same it becomes important that the medical data entry professionals have a good medical background which helps them process the data efficiently. A budding up option for recording the patient information also includes the voice or speech recognition (SR)systems where the physician need not maintain any paper records at all for the conversation held with the patient but has to instead only deploy a SR system at his clinic which would record the conversation (the S/w is programmed to catch and record the doctors voice), now these recorded messages are processed and transformed into digital records by a professional medical transcriptionist (MT) . Again here a a possible hurdle could be the doctor's accent which could be overcome by providing prior training about the general language, slang and accent specific to the doctor's country or state to the MT.

Types of Medical Reports that you can Outsource

Here are some types of medical reports that you can outsource for data entry:

1. Patient History & Physical Examination Report - :This contains brief information such as patient name, age, gender, occupation, family health history, lifestyle habits like smoking, drinking etc. along with details of the physical examination.

2. Consultation Report When the doctor examines the patient, all the details of the consultation are recorded. This information comes handy if the patient goes to some other physician for further treatment or diagnosis. Thus the data needs to be recorded correctly in the patient profile.

3. Operative Report It contains all the details of an operational procedure or surgery that includes details of the procedure, duration along with certain post-operative details.

4. Radiology Report In case of radiology treatments and MRI scans, CT scans, all the details of the findings need to be recorded.

5. Pathology Report In case of pathology treatments, the findings of the tissue samples need to be recorded.

6. Laboratory Report The details of findings on body fluids need to be recorded.

7. Emergency Report In case of emergency cases, it becomes all the more important to record the summary of the patient's visit emergency care to aid further treatment.

8. SOAP Note Report This is an extremely detailed and complex report that consists of 4 parts. All the information needs to be recorded and entered into the databases.

Subjective Contains details about current condition of a patient such as age, gender, and pertinent symptoms etc.

Objective - Contains information about vital signs and findings from physical exams.

Assessment - Contains summary of symptoms and diagnosis etc.

Plan - Contains treatment plans for the patient with reasonable time lines etc.

9. Progress Note Report This report records the progress of the patient treatment and requires ongoing data entry services.

10. Discharge Summary When the patient gets discharged from the hospital, all the details pertaining to the treatment given, progress of the patient including any findings needs to be recorded.

While outsourcing the record keeping or database management task for any of the above categories of medical reports it should be thoroughly verified that the selected outsourcing partner selected is a reputed and reliable vendor for the desired services. As the medical reports of patients contain all the data which at times need to be kept under covers or should not be leaked out on Internet or else it could be misused, because such cases can lead to litigations against the doctor or the involved pharmaceutical company or hospital. The access to such records is generally restricted to the concerned or other member medical practitioners.

Keeping record of the patient information is important to keep a track of the patient's medical progress as well it could be used as as studies for various research purposes. The option to outsource this task to other professionals rather than the doctor doing it himself assures that all the patient information is recorded accurately, completely and in compact digital format from where it can be easily retrieved for future use and reference while maintaining the confidentiality of the data.

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