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01 Oct 6 different types of medical documents

When you are a medical translator, you may face different kind of documents. But, which ones? Okomeds – a medical and healthcare translation agency – lists and briefly explains you some of the most common ones.

6 different types of medical documents

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.