A medical record summary is a concise, structured overview of information related to a patient’s medical history. The medical record summary includes any information from the patient’s medical file that is relevant to the summary user. For example, a medical record summary might include information about hospital visits, doctor’s decision letters, or treatment plans. The medical record summary can also include progress notes or diagnostic information. 

The purpose of summarizing medical information is to condense the extensive (and often lengthy) patient file into a single report for concise use. How this report will be structured can differ depending on the industry where it will be used. Healthcare providers will be looking for different information than claims providers and legal teams. Due to this, medical summaries must be carefully structured and created to provide the most useful – and accurate – summary. 

Structure of a medical record summary

Medical record summaries are the end result of many summarized reports. Hundreds (or even thousands) of documents containing information on hospital visits, checkups, diagnostic tests, and recommendations must be compiled into a single summarized report. 

Artificial intelligence (AI) platforms can complete this medical record compilation more efficiently than a human administrator. These AI models rely on titles, headings, and other “structural features” included in medical records to understand what the records contain. Prompts designed by medical professionals can help the machine learning tool pull out relevant information verbatim – without veering into opinion-based or abstractive summarization. The end result is a compiled “summary of summaries” that includes relevant information on each document in the patient file. Medical record summary reports are also easy to read for the end user, thanks to headings and titles added to the final document. 

Documents to include in a medical record summary

Medical record summaries will contain background information on the patient or claimant. Depending on the background and professional knowledge of the user requesting the medical summary, specialized prompts are used to produce the summaries required for relevant documents: for example, decision letters, diagnostic reports, legal documents, and so on. 

These medical reports require reams of information about the patient, including:

• X-rays, lab tests, or pathology reports
• Doctors appointments or other clinical visits
• Hospital visits
• Treatment reports and recommendations
• Patient medical history or recollection of accident given in interviews (if conducted)
• Patient medical history given by family doctor or hospital
• Interviews relating to the accident or injury
• Police or accident reports from eyewitnesses (if an accident led to the claim)  

These documents provide context for the nature of the injury or claim, tests performed, treatments provided, and any previous visits to medical practitioners or experts that the patient has made. All of this information will impact the outcome of the claim, so medical records are used to support the patient's background summary, the decisions made, or the services being performed when it comes to the medical care provided and the claim’s resolution 

Information to include in a medical summary 

Important information for a medical summary is often pulled via the SOAP format: subjective, objective, assessment, and plan. This SOAP format is the backbone of medical summarization. 

• Subjective information is based on opinion or emotion, such as the patient’s recollection of an accident. 
• Objective information is fact-based, such as a patient’s vital signs. 
• Assessment refers to the medical practitioners’ review or assessment that has taken place when they have seen the patient
• Plan refers to medical recommendations for treatment, such as medications prescribed or surgeries performed or recommended. 

The needs of the end user will determine how detailed each component of the medical record summary will be. For example, legal documents are lengthy and detailed. Documents such as a deposition will contain subjective information from the witness who is asked to testify. Subpoenaed medical records will provide objective information such as treatment times and dates. Combined, these can provide a fuller picture of the patient and the claim. Healthcare providers may not need to see the results of a deposition, but will probably need to know more details about the tests performed. For these cases, a summary of the patient’s background and incident information may suffice. In both healthcare and legal cases, a chronology of the patient’s medical history might be required. 

‍Medical record summaries are carefully constructed documents that offer legal, healthcare, and insurance professionals a wealth of information in a fraction of the time. Advances made in machine learning and artificial intelligence now make it possible for the professional to flag and examine each document relevant to a patient’s file – without sacrificing valuable processing time!