Why Expert Review Services May be Necessary for Accurate Medical Record Review and Analysis

Author: Medical Record

For any prosecuting or defense attorney handling a medical malpractice, workers’ compensation, vehicle injury or mass tort case medical record analysis and review is of great significance. This is something that demands excellent expertise and is best provided by a medical record review company that offers the services of a good team that includes a legal medicine physician. The physician reviewer may act as a consultant or as a non-testifying expert witness. It is not easy for a non-medical person to interpret medical records. Medical record analysis includes:

  • Interpreting the information found in the records
  • Identifying missing information if any
  • Identifying tampering if any, in the medical chart
  • Determining if the medical chart is complete

So naturally reviewing medical records in a personal injury case, calls for the services of an expert review team.

Medical Record Organization to Understand the Sequence of Events

Now let us consider the task of medical record organization. When you request medical records, medical providers usually provide them as they come off the scanner or copier. This may be in reverse order. In a law firm, the records are organized mostly in the manner in which they are received and if this is in reverse chronological order it may be quite challenging for the reviewer to have a clear understanding of the sequence of medical events. If the records are organized by a professional medical review team, they would ensure that the documents are arranged chronologically in the exact sequence in which medical treatment was provided to the patient. Apart from ensuring a chronological listing of all the medical encounters, this would also make sure that all personnel in a litigation team have the valuable medical records indexed in the same manner.

Reviewing the EHR – Important Considerations

Now, hospitals and other medical providers are required to use EHR or electronic health record systems. Providers have to record the patient information into the EHR; this system also helps hospitals to verify that services were rendered for third party payer audits. The information contained in an EHR system is discoverable and therefore legally significant.

So what are the components of an EHR system?

  • If the patient is admitted into the Emergency Room or ER, he/she gives personal information to sign into the system.
  • In the treatment room, nursing personnel record past history, vital signs, allergies and current medications in the EHR.
  • Then the treating physician will enter details such as the patient’s chief complaint, HPI or healthcare personal information, ROS (review of systems). The HPI and ROS are usually audited by third party payers for compliance. The physician would also record details of the physical examination of the patient (for each body system) into the EHR.
  • The MDM or medical decision making section in the EHR will contain details regarding the findings of test results such as that of imaging, lab tests and EKGs. It will also contain a short description of the care provided during the patient’s visit.
  • The other important EHR entries are medical diagnosis (specific causation), differential diagnosis (general causation of the health condition), treatment plan/referral plan, and finally the condition of the patient when discharged.

Reviewing the Medical Documentation

Here are the important considerations when performing a review of medical documentation.

  • Make sure that you have received a complete set of medical records and that they are of the correct patient. You need to ensure also that there is a proper HIPAA-compliant release of healthcare information signed.
  • Once the records are collected and organized, find out if there is any altered information. Study the records carefully to understand the course of events. Look for medical events that should have occurred but didn’t.
  • Have a clear understanding regarding who all provided care, providers who should have been present but were not; also, have a clear idea of the care provided and omissions or negligence if any.
  • Study the pharmacy notes and nursing notes to spot any discrepancy with the physician’s notes.
  • From your analysis you should be able to decide whether the available medical evidence supports or defends the causes of action at issue.
  • You also have to determine whether you need testifying expert witnesses from specific medical specialties are needed.
  • In a wrongful death case, it is important to ensure that you are within the shortened statute of limitations. Get a copy of the death certificate and supplemental certificate. Find out the cause of death and compare it to details in the injury claim.

Specialized Medical Record Analysis and Review Services Can Help

Given the tediousness and complexity involved in the review process, it is always a practical option for attorneys to obtain reliable services from a medical record review company. They offer the service of licensed physicians to review the medical records and sign off on the review and summary if required. All important medical information in the records is correctly interpreted and summarized for easy perusal by the legal team. The summaries are concise and customized to meet your unique litigation requirements. The comprehensive review of the patient’s healthcare documentation ensure that you have all the information you need such as hospital stay, findings of tests and examinations, opinions of medical professionals involved as regards causation, disability, medications, diagnostic test results as well as the deposition testimony of the patient. It will help you scrutinize the records quickly and determine whether it is worthwhile to take up the case.