Patient’s diagnosis is always supported by appropriate diagnostic findings and thus they become an inevitable part of the medical records. Physicians would like to review the past diagnostic findings on the patient, they do carry out different tests for confirming the diagnosis. These diagnostic results become part of the history and also can be a part of the physical findings and can be ordered as a part of the treatment plan. Also, there are separate documents generated for different studies carried out.
Importance of Diagnostic Testing:
Diagnostic studies have immense importance in the treatment of any patient. The results or observations from the studies are the prime sources to confirm the diagnosis. They are used in
- Identifying disease, e.g. bronchovascular markings and patches are seen on the x-ray can confirm pneumonia based along with clinical symptoms.
- Identifying the location of the disease, e.g. CT scans and MRIs are done on the patient to find out the exact location of the tumor or injury deep inside the body.
- Classifying the diagnosis, e.g. anemia can be classified into its types based on the peripheral smear examination showing morphological differences in the blood cell structure.
- Monitoring the status of the disease, e.g. frequent lab tests like blood sugar, thyroid testing, cholesterol testing are done to evaluate the status of the disease.
- Monitoring the progress of the patient, e.g. Lab tests like electrolyte testing and BUN/Creatinine are done in dialysis patient to evaluate the kidney status.
- Finding causality of any complaint, e.g. for abdominal pain, abdominal ultrasound is carried out to find out if the gastrointestinal system, or urinary system or reproductive system or just muscular system is involved.
Types of Diagnostic Testing:
There are various types of diagnostic testing based on the technology used:
- Laboratory Studies: This includes various tests carried out on body fluids like blood, urine, semen, CSF also faces.
- Pathological Studies:
- Radiological Studies: X-rays.
- Imaging Studies: Sonography, MRI, and CT Scan.
- Other Studies: Pulmonary function tests.
Diagnostic Testing and Medical Records:
Addressing findings in the medical document is necessary. Physicians many times scribble these findings wherever they find a place with short forms used and symbols used for their reference during the patient encounter. Mentioning this data properly in the electronic health records is a challenge. If the numbers are missed, wrong units are applied or handwritten data is misinterpreted this can cause a big impact on the patient’s treatment process. Interpreting the data accurately invalid format with correct units if required is very necessary when we consider any diagnostic study data interpretation in the medical records. Of course, normally there are actual reports available to verify the data from medical records and they also need a proper interpretation when the data is considered for treatment. Whom can we trust to interpret medical records including diagnostic data and diagnostic reports accurately?
ITCube Is The Right Option!!
ITCube is dealing with such types of records over a decade now. With the team of medical experts on board and very large experience in managing medical diagnostic data and records, ITCube can process and rightly interpret 1000+ tests carried out frequently and very special tests carried out for unique cases. Meticulously interpreted and appropriately formatted diagnostic data helps medical professionals, lawyers and claim executives to treat the patient in the more satisfying way. Medical data summarization can prove a complete solution to this.