Summarizing medical records is a little like working a jigsaw puzzle. Put together, or summarize, the pieces you do have, and they’ll lead you to the missing pieces, or the rest of the complete medical history.
Use every bit of information at your disposal, including (but not limited to), client contact, medical bills, medical records, pharmacy printouts, rehabilitation reports, disability statements, and health insurance EOB statements to add everything to your summary that you do know, even if it’s just a date of service, the type of medical treatment, or the name of a medical provider.
I even include the dates and names of medical providers for upcoming appointments, noting “pending visit” on the summary.
Got a medical records summary tip? Email it to me at firstname.lastname@example.org, and I’ll turn it into a post, giving credit where credit is due of course!