Every hospital report can be constructed in a modular fashion using intelligent building blocks. While these building blocks are not boilerplate text, they represent a logical grouping of certain types of information. Each health facility's Medical Record Committee may request that this data be formatted in a certainorder. The ultimate goals are clarity and standardization.
Because many physicians are only concerned with dictating a report and getting the job done, they fail to think about how that report must be used and interpreted by others who read the finished product.
- A consulting physician, Emergency Room physician -- or any other healthcare provider who is examining a patient -- needs to quickly and accurately be able to find the information he is looking for.
- Knowledge workers in the health information management (HIM) industry --such as coders and abstracters -- must be able to find the information they need so they can extrapolate data for billing and other purposes.
If reports are constructed so that patient information is arranged in a logical sequence, it is much easier to find and interpret the information at a later date. Think of the golden rule when organizing your thoughts before dictating:Do unto others as you would have them do unto you.
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