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    What Is A Medical Document

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    Irina
    Medical documents contain information necessary for patient care and can be clinical or non-clinical. Clinical documents include a patient's medical history and health information, which is important for treatment. Non-clinical documents involve administrative information needed for managing resources and coordinating care between departments. Medical documentation creates a foundation for diagnoses and treatment by allowing healthcare providers to quickly understand a patient's health history.

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    What Is A Medical Document

    Uploaded by

    Irina
    19 views2 pages
    Medical documents contain information necessary for patient care and can be clinical or non-clinical. Clinical documents include a patient's medical history and health information, which is important for treatment. Non-clinical documents involve administrative information needed for managing resources and coordinating care between departments. Medical documentation creates a foundation for diagnoses and treatment by allowing healthcare providers to quickly understand a patient's health history.

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    What is a Medical Document

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    Medical documents contain information necessary for patient care and can be clinical or non-clinical. Clinical documents include a patient's medical history and health information, which is important for treatment. Non-clinical documents involve administrative information needed for managing resources and coordinating care between departments. Medical documentation creates a foundation for diagnoses and treatment by allowing healthcare providers to quickly understand a patient's health history.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    19 views2 pages

    What Is A Medical Document

    Uploaded by

    Irina
    Medical documents contain information necessary for patient care and can be clinical or non-clinical. Clinical documents include a patient's medical history and health information, which is important for treatment. Non-clinical documents involve administrative information needed for managing resources and coordinating care between departments. Medical documentation creates a foundation for diagnoses and treatment by allowing healthcare providers to quickly understand a patient's health history.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    WHAT IS A MEDICAL DOCUMENT?

    Medical documents are legal documents. They contain the information necessary for the correct
    care of patients and include information of a healthcare, preventive and social nature. We can
    differentiate between clinical and non-clinical documentation.

    Clinical documentation is the patient’s information that includes their biological history and all the
    information that the healthcare professional attending the patient should be aware of. For this
    reason, it is important to keep good clinical records for better treatment and patient adherence.

    In contrast, non-clinical documentation involves those administrative documents necessary in the


    care process. Therefore, non-clinical documentation is understood as those documents of a social or
    administrative nature that allow for good management, coordination and organisation of the available
    means and resources, as well as the correct functioning of the different departments that make up
    the care process, such as the interrelation between Primary Care and Specialised Care.

    Medical documentation is an essential aspect of the patient care process. This information allows
    the treatment and diagnosis of the possible ailments that the patient may present to follow the same
    line. In other words, it creates a foundation underpinning the different interventions involving the
    patient in the care process. In this way, it allows the professional on duty to have a quick overview of
    the patient’s health, allowing for quicker and more effective diagnosis and treatment.

    PIL
    A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy. It
    contains very important information about the product such as its conditions, side effects, doses or
    conservation. A medical and healthcare translator must pay a special attention to the country
    regulations and quantities.
    Medical history record
    A medical history record summarizes a patient’s medical history and also includes some notes and
    remarks made by healthcare specialists. It can be used in a clinical environment, and the medical
    and healthcare translator should never misunderstand the contained information.

    Discharge Summary
    A hospital discharge summary is prepared when a patient checks out of the hospital. It normally
    explains the reasons for the hospital admission, the results of the tests made, and how the patient
    feels after the discharge – with some medical advices.

    Medical test
    It includes a blood test, an urine test, a heart test, and many other variants. Figures, chemical forms,
    molecules, quantities… everything have to been carefully looked by the medical and healthcare
    translator.

    Mental Status Examination


    It details the results of a mental exam. Is the patient in his/her right mental abilities? A medical
    specialist will present the results in an official document which may required a medical translator.

    Operative Report
    It is a report prepared to detail the procedures and findings of a surgical operation. The medical and
    healthcare translator should avoid any ambiguity and be as clear and concise as possible.
    As stated hereinabove, these are some of the most common types of medical documents that a
    medical and healthcare translator may find, but not the only ones. A translator will probably run into
    many other types as well, so he/she must be familiar with many types of medical documents in order
    to succeed in the job.

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