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Medical records review involves gathering and analyzing an individual’s medical records, including hospitalization records, medical history reports, and laboratory results. Attorneys for both plaintiffs and defendants may need to conduct medical record reviews to support or defend clients against various claims. These claims include personal injury claims, mass tort cases, medical malpractice claims, product liability claims, and workers’ compensation claims.
The following article explains how medical records reviews can assist you in supporting a variety of healthcare-related causes of action and the benefits of outsourcing the task.
The purpose of medical records review is to analyze voluminous patient records within the healthcare system. The examination of these records can help determine things like patient diagnoses, needed medications, medical history, lab testing, physician evaluations, and treatment plans that may be pertinent to support your clients’ claims or defense.
If a firm has adequate resources and access to an individual with medical knowledge, in-house professionals can complete medical records reviews. When that’s not feasible, the task of reviewing patients’ medical records is incredibly labor-intensive. It often requires consultation with experts in the medical field, such as a nurse or physician. These specialists are used to decipher medical terminology and know where to find meaningful information relevant to your client’s lawsuit or insurance claim.
Outsourcing the review of your medical records to a company trained and equipped to perform the service ensures that qualified legal nurse consultants or physicians adequately review, thoroughly analyze, and efficiently organize your clients’ documents.
Review of medical records is essential for lawyers to support claims (e.g., insurance claims) involving injured individuals who sought or are seeking medical treatment, including:
Medical records are typically divided into various sections and may be organized differently depending on the hospital’s recordkeeping practices. All medical files generally contain the same types of records, chart reviews, and other documents containing patient health data, including:
An admission record is usually the first page of a medical record. It contains the patient’s personal and financial data, including the patient’s name, address, age, date of birth, sex, race, marital status, religious affiliation, and nearest relative or emergency contact. It should also contain a short description of the patient’s condition upon admission, suspected diagnoses, and the name of the attending physician who is treating the patient.
You can also find the history and physical report near the front of the compilation of the records, if present. It contains the doctor’s initial observations, the patient’s past medical history, and family medical history. It should be typed and signed by the doctor.
Doctors’ progress notes are usually handwritten, making them difficult to decipher. They also tend to be less comprehensive than nurses’ notes. Still, they are often most helpful in understanding the chronology of treatment and usually include the doctors’ reasons for treatment decisions and patient care.
Since additional or specialty consultations are not always necessary, the patient’s medical records may not always contain a consultation report. If present, the report includes evaluations and recommendations from the consultant.
Physicians’ orders detail the medications and treatments prescribed to the patient and any necessary instructions. Physicians do not always keep these records daily. The forms are usually in triplicate—the white copy stays in the medical file; the pink carbon copy goes to the laboratory; and the yellow carbon copy goes to the pharmacy. Once the relevant parties fill the orders, the medical offices destroy the corresponding pink and yellow copies.
Physicians’ orders may be relayed to and signed by a nurse on behalf of the treating physicians, or the orders may be handwritten by the doctor. It’s also possible that the orders may be in a non-triplicate typewritten form if the hospitalization was for a routine procedure.
Laboratory reports include patient results for bloodwork, pathology, blood typing, and other clinical tests. These reports are usually on separate, smaller forms.
Diagnostic reports include radiology and X-rays, CT scans, ultrasounds, EKGs, EEGs, and cardiac output data. Medical practitioners usually sign these documents with a stamp rather than a signature. X-ray films and CT scans are not routinely provided with the patients’ medical records and must be requested separately.
Healthcare providers generally divide anesthesia records into pre-anesthesia, anesthesia, and post-anesthesia forms. The pre-anesthesia record may also be found in the operative report and describes the patient’s previous medication history and the choice of anesthesia due to the planned procedure. The anesthesia record details the type of drugs administered to the patient, when given (i.e., date and time), and notes on the patient’s condition during surgery, including any complications from the anesthesia. Lastly, the post-anesthesia record includes an evaluation once the patient is in recovery.
Someone typically prepares operative reports per dictation, so it’s possible they contain inconsistencies or might be missing data, making it essential to check these notes carefully. The operative reports describe the technical aspects of surgical procedures, the surgeon’s name, the bodily tissues affected by the operation, the condition of the patient after surgery, and additional post-operative diagnoses.
Nursing notes provide daily summaries of patients’ conditions, needs, limitations, appetites, complaints, and appearances. These notes are most often the best source of information and may include graphic charts, I/O reports, and medication reports.
This report includes instructions provided to patients by nurses regarding treatment plans, diet and activity restrictions during recovery, medications prescribed, and any symptoms to report. The on-duty or treating nurse and the patient sign this document upon discharge.
Discharge summaries provide an overview of a patient’s visit and hospital stay. The document includes physicians’ findings, a summary of diagnoses, medications prescribed, and instructions given to the patient upon discharge. A discharge summary is often in typewritten form, dictated by the primary care physician, including a transcription date and the doctor’s signature.
The attestation is the last document included in the file after the discharge summary. It should contain a summary of the patient’s diagnoses without using medical abbreviations and the treating physician’s signature.
Before you can review and analyze necessary patient medical records, the first step is medical records retrieval . Similar to the review process, medical records retrieval can be an arduous and time-consuming task due to rigorous HIPAA standards and the number of providers and records within a medical file. Once obtained, there are various steps to review these records accurately and effectively, including:
You can measure the value of medical records reviews by the benefits they provide in proving various healthcare claims, identifying error patterns in healthcare services or practices, and monitoring the effectiveness of different medications and courses of treatment. Depending on the nature of your case, medical records review analysis services are essential for several reasons:
Medical records reviews are vital tools for substantiating health-related claims against a variety of defendants, including:
Medical records reviews provide you with organized, easily understandable records of your clients’ medical treatments before and during alleged incidents. For personal injury cases, this record is crucial to prove the nature and extent of client injuries, keeping track of treatment received, and documenting the potential for future needed medical care. A detailed and accurate medical chronology can help rule out pre-existing conditions that the defense might argue contributed to your client’s injuries. Proving damages and causation are two essential elements of a successful personal injury claim.
Besides establishing the basic elements of a personal injury claim, having a complete and well-analyzed medical record is helpful to assess the potential strengths and weaknesses of your case and determine how much your claim may be worth for settlement purposes. The amount of compensation an injured person can receive depends on:
Most importantly, an accurate and detailed medical record can help prove (or disprove) causation. The burden of proof for personal injury cases rests with the plaintiff. Objective evidence, including physician statements, laboratory tests, and radiology films, is much more difficult to refute. Having these documents organized and prepared in indexed files helps corroborate a plaintiff’s claims without hesitation or error.
Detailed medical chronologies are essential to demonstrate that the plaintiff’s condition did not pre-date the incident and clearly outline an injury’s continuing nature and course of treatment. Finally, quantifying damages for pain and suffering, loss of quality of life, or even loss of consortium is always a difficult task, but using detailed summaries and medical chronologies can help substantiate these claims.
If done in-house, legal assistants or document reviewers who often have little understanding of the complex medical processes and terminology will complete the job, sometimes resulting in the oversight of meaningful information. Instead, medical records review companies rely on medical consultants who have extensive knowledge of the healthcare industry, as well as years of experience deciphering medical terminology, procedures, and recordkeeping practices. These professionals are also familiar with state medical records review guidelines .
The process of extracting pertinent information from medical records includes:
How long medical records reviews take depends on the size and complexity of the patient’s medical file but can take up to several weeks for a file of around 1,000 pages. Medical records reviews are laborious, but some service providers may offer expedited reviews when courts or other circumstances present tight deadlines.
Medical records services may vary slightly depending on the type and complexity of your claim. Services provided generally include the following:
A thorough review of your client’s medical records can vary in cost per provider. Most companies also base their pricing on the specific services requested. Factors influencing your overall cost might include how many documents need reviewing, whether the documents are complete or illegible, and how much organization is needed.
Some law firms have the necessary resources to complete medical records reviews in-house, but we highly recommend that you outsource your medical records reviews to an experienced team, employing medical professionals available for consultation. Also, hiring a vendor to assist with your medical records reviews ensures that your clients’ medical files and document analyses are secure and fully compliant with HIPAA standards.
Conducting an effective and thorough medical records review without the help of a medical expert can be extremely difficult for many reasons, including:
Reach out to CAMG today to learn how our highly trained staff can assist you with your medical records retrieval and review needs!