Summarize or Plagiarize a Medical Chart Review?

05 October 2012 / Chart Reviews, How To / Comments Off on Summarize or Plagiarize a Medical Chart Review?

This is an interesting question.

Some reviewers will summarize chart notes. It will generalize the nature of the visit, the contents of the findings, in the opinions of the doctors. I personally prefer taking the actual excerpts of the chart document notes and including them in the review section.

I do this for the following reasons. First, I do not want my “opinion” to replace the chart information. I like the reader to read exactly what I have read, so there's no misunderstanding on what is presented in the chart.

Second, I like to use quotation. Quotation is valuable to make a highlighted comment on a specific opinion are finding in the medical chart review.

When using quotations, it is important however, not to take them out of context. Using quotations incorrectly may result in your report as being viewed as “biased” for one side or the other. If the employee or doctor makes a statement, that is critical or contradictory, I may consider that section of the chart as a quotation.

Finally, when selecting direct text into the chart review, the use must be judicious. Remember, writing and editing is an active, if not aerobic, process. It requires thinking and editing.

Read what you have selected. Does it add to the value of the report? Keep clear in your mind what is subjective and what is objective in the review being created.

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