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The Diversity of Medical Documents

When we think about medical documents, we might be inclined to envisage extremely specialized material with which we are completely unfamiliar. However, translated medical documents are all around us and range from very technical and dense, to public-oriented and accessible. The best medical translators know the characteristics that distinguish each text-type and can identify their end-goals in order to carry out their jobs more effectively.

Today, we will go over nine very common documents in medical translation, from patient information leaflets to operative reports. Ready to explore the diversity within this broad field?

1.    Medical Record

First up, let’s have a look at medical records. As we become a part of the healthcare system, a medical record is created to systematically compile the details of every patient’s history. All the information about each individual’s health can be found in one document, for medical professionals and patients to use as reference.

2.    Patient Information Leaflet

Often abbreviated as “PILs” and alternatively referred to as “package inserts” or “instruction leaflets”, these medical documents are oriented towards the general, non-specialized public and are generally located within a product’s packaging. Because they have not been written for medical professionals, the language in them tends to be simpler and straight-forward, with as little specialized terminology as possible.

3.    Instructions for Use

Instructions for use, or “IFUs”, are medical documents that detail the way in which a medical device must be operated. When using a medical device, we all expect that it comes with a guide on how to use them. Its clarity is very important, as it includes not only instructions but also warnings and safety information.

4.    Discharge Summary

These medical documents are drafted to communicate the patients’ care plans to other medical professionals once the former have been discharged from hospital. Discharge summaries (and their correct translation) are important because they help maintain patient safety and well-being during the time following hospitalization.

5.    Medical Test

Many different medical tests can be carried out to make crucial decisions when it comes to the detection, diagnosis, and treatment of diseases. These documents tend to be very technical and hard for patients to understand. The vocabulary is highly specific, varying according to the test and the health specialty, and there are plenty of acronyms and abbreviations.

6.    Mental Status Examination

These medical documents involve the assessment and description of behaviors and cognitive functions, including aspects such as the attentiveness, speech, mood, and attitudes of a patient. The information gathered is then cross-referenced with the patient’s history (available in medical records, mentioned above) in order to reach a diagnosis.

7.    Operative Report

Towards the most specialized end of the continuum, we can find operative reports, drawn to record details of a patient’s surgery. Operative reports are also included within medical records and are particularly useful for other health professionals who will be looking after the patients during the post-operative period and recovery.

8.    Informed Consent Forms

Informed consent needs to be obtained before any intervention can be conducted on a patient, and it is a prerequisite for disclosing patients’ personal information. Informed consent forms are public-oriented, and need to use simple language in order to convey an intervention’s possible risks and benefits, as well as the procedures it involves.

9.   Patient Diaries

These documents are used during clinical trials or as a part of a treatment in order to find out more information about the patient’s health. Medical professionals also use them to assess patients’ compliance with the treatment prescribed. These diaries can be kept by health professionals, family members and friends, and the information can be used to help patients get their heads around their illness.

MEDICAL DOCUMENTS AND A NEED FOR MAINTENANCE

Because of these documents’ importance, most of them are regularly updated and edited. If they have been translated, the update involves adding any new information and transferring all edits to the previously translated text. Although this can sound like a tiresome process, with the use of translation memories, professional linguists can shorten turnaround times by using specialized translation software to spot the differences from the last translated version, and concentrating on the additions and changes.

Learn more about Ocean’s medical translation services here.

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