Type Of Dates In A Single Record Having Specific Importance....

Healthcare industry has other dimension of medical records apart from patient and caregiver. These records play vital role not only in treatment of the patient but also in settling the medical claim amounts or as a legal reference for any lawsuit. One must agree that the date of the medical records is equally important when we think about medical data in the reports. There may be various types dates in a single record having specific importance.

1. Date of Visit (DOV): Date of visit to the doctor. This date is very important to arrange medical records chronologically and to help understand flow of sequences during visit.

1. Date of Examination (DOE): Date of examination like x-rays, labs, various tests. There are also few more categories in this section like date of blood drawn, date of testing and date of reporting.
2. Date of Surgery (DOS): Date of surgery occurred on the patient.
3. Date of Birth (DOB): Date of birth helps to confirm the age of patient and can be one of the data confirming that these records belong to which patient.
4. Date of Death (DOD): Generally, after the date of death is noted on any report, one can expect no further medical records except for autopsy and organ donation records.
5. Date of Admission (DOA): This date indicates admission of the patient to hospital ER or IPD. Detailed medical history and examination follows date of admission.
6. Date of Discharge (DOD): Discharge from any facility, service, treatment is an indicator for treatment summary and future treatment plan including plan of care and instructions.
7. Last Mensuration Date (LMP): This is a vital information for any Obstetrics/GYN report. Estimated date of delivery is calculated based on LMP.
8. Date of Delivery (DOD): Commonly noted in delivery or postpartum records and can be a part of GYN history for other reports.
9. Date of Injury / Incidence(DOI): Considered as an initial point for treatments. Date of injury is prime for any claim or lawsuit.

It is very important to use these dates in structured fashion. Based on the dates all the records are arranged in ascending or descending chronology which help end user to identify sequence of the events and get key time points for any legal investigational aspects. Proper identification of dates also helps to correctly calculate treatment time, treatment milestones and its related billing pattern. Deep investigation of all the above helps to find loopholes in treatment present if any.

As medical records have multiple dates, it is very important to understand importance of each date, locate dates mentioned in different format and mention them rightly in the extract.

For that:

1. Locate right date/s.
2. Understand the correct format of the date (DD/MM/YYYY or MM/DD/YYYY).
3. If the document is handwritten, understand smallest difference between handwriting stroke pattern and check for accurate date.
4. Confirm the date with supportive documents. Inform end user about any date discrepancies.
5. Mention in the abstract in desired, agreed standard format.

All the medical records are basically arranged based on date of activity. Accurate date location and incorporation this vital data in medical data review is key of any successful claim management or lawsuit.

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