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8 Best Medical Record Review Techniques
Medical record review is an essential process for ensuring the medical information’s accuracy and authenticity. Medical records are most commonly reviewed by medical facilities and centers for treatment planning and insurance claim purposes and by lawyers for preparing a case, especially for medical negligence or litigation such as personal injury.
As these records are made up of documents about a patient’s medical history, it is vital to keep them well-organized. Doing that will help not only patients and hospitals but also attorneys who handle medical malpractice and personal injury cases.
What is The Importance of Medical Record Review?
While handling a case that involves medical records, attorneys must study those records and completely understand the details while also checking for errors and mistakes. This is because even a small error can lead to inaccuracy and have legal implications. Due to improper or incomplete maintenance of medical records, there are high chances of losing trials.
A detailed review of case-relevant medical records is highly important for attorneys and litigators, especially when assessing a medical or legal claim including medical malpractice, workers’ compensation, product liability, medical or insurance fraud investigations, etc.
Since medical records contain key information about a person’s health over a period of time, attorneys can use them as strongly valid evidence to prove their client’s claim and win the case. Attorneys must sort records in chronological order because otherwise, it can create confusion. Moreover, systematically-organized records make it easier for attorneys to review the documents in a fast manner.
However, the road to victory is not as easy as it seems. They need to go through all the documents in detail to use them as a key or supportive evidence and this consumes a lot of time. This is where personal injury litigation support providers come into the picture. They can support attorneys with various legal back-office functions including medical record review, helping them summarize the records into short and easily readable formats all while sequencing them chronologically.
What is Included in Medical Record Review Services?
- Organizing medical records
- Establishing an accurate chronology/timeline
- Writing case summaries
- Categorizing medical records
- Identifying missing records
A Typical Process Used by a Medical Record Review Service Provider
- Retrieval: The attorney retrieves the required medical records from the concerned medical facility.
- Review: A paralegal or specialist reviewer from the service provider’s team will conduct reviews, checking for facts while being unbiased.
- Summarization: Post analysis, they will draft a precise summary out of the voluminous records in a reader-friendly format.
- Supportive Reports & Timelines: For a better understanding of the facts described, they add special reports to support the records and mention timelines.
- Adding Links: They will add bookmarks or hyperlinks to help the reader check references (source records) quickly.
- Quality Check: A team of expert auditors will check the final draft to ensure all the information is accurate and valid.
- Submitting the Final Drafts: The final drafts will be submitted to the client-attorney or -law firm via a highly secured file transfer platform.
Let’s now discuss some of the best medical record review techniques in brief below;
Best Techniques for Reviewing Medical Records
Understand & Learn All Medical & Legal Terminologies
People are habitual of using common words for various medical problems such as high blood pressure. However, when it comes to presenting a case in court that involves this condition, all attendees including the judge would expect to hear it as hypertension.
It is a small example of what terminology is used in medical records and hence, as an attorney, you must know and understand all case-relevant medical as well as legal terms.
Collect All Required Records
The actual process of medical record review begins with the collection phase. It would be best to collect all important medical records from as many sources as available. Additionally, HIPPA guidelines and other strict data protection laws safeguard the medical records of patients.
Therefore, you must get prior permission from the concerned patient before requesting their healthcare provider for access to medical records.
Demographic Data Cleaning & Validation
Before beginning to dig into hundreds of medical papers (sometimes thousands), it is time for filtering the records so that to have only precisely relevant papers and then validate them too. In this phase, you need to spend a good time reading and understanding records and identifying irrelevant records.
Once you have useful records in hand, look for information that is incorrect or incomplete. Make sure you rectify the false information by double-checking facts with the information source.
Indexing – Prepare a Medical Chronology
This technique can be used in the finest manner in personal injury cases. During the review phase, placing well-organized factual information with supporting documents in the right order can play a key role in pre-trial claim settlement.
While preparing these records, describe medical events in order following their sequence of occurrence, using a range of keynotes and documents including, the date of injury or hospitalization, doctor/nurse observation notes, diagnosis reports, treatment procedures, prescriptions, patient’s condition over time, alternative remedies, and anything admissible.
This report can also help emphasize the impact of the injury on the patient/claimant.
Interpreting Handwritten Notes Right
The legal sector has been reluctant toward digital technologies for a long till a few years ago. However, digital adoption peaked during the recent pandemic and it is still growing.
Still, as a medical record reviewer, you should have the ability to read handwritten medical papers, for example, nurses’ or doctors’ initial consultation and observation notes. For this, the best you can do is learn important medical shorthands because you will commonly find them in these notes.
Don’t Misinterpret – Do a Fact-check
During the entire course of your career, you must have seen a few handwritten medical records with a lack of readability or clarity. Similarly, there might also be some printed poorly copies, making them almost impossible to read, let alone interpret.
For example, you might see the incorrect specification of a medicine in a printed prescription, for example – 20 mg. There can be a possibility that the paper or ink quality was poor and that is actually 200 mg as that medicine is not available in 20. Checking this information on the web or with an expert can help ensure you do not misinterpret it.
You should also contact the source of information and request the original, easily-readable record. Illegible records may not be considered important until you get a clear and readable enough copy of them.
This technique is no less than a tool to eliminate duplicity that may lead to confusion. Repetitions might reflect that the lawyer who is handling the case is himself not sure about the chain of events. Consequently, this can waste the efforts you put in while preparing the medical chronology. Here’s the best opportunity to use your eye for detail. Keep a short note of records and documents you have reviewed.
One of the bests ways to do that is to tag them with numbers according to the dates you obtained them and the names of the sources. Doing this will ensure you don’t repeat records while attaching even if you have received multiple copies of one record from a medical facility or other external sources.
Read Fast – Finish Fast
This is one of the underestimated skills of an attorney but is very important in today’s fast-paced world. Moreover, attorneys cannot afford to read slowly because they usually handle multiple cases and they need to meet clients while managing many other more important responsibilities. Therefore, it would be an excellent skill of yours if you improve your ability to read faster.
However, it is not about how fast you roll your eyeballs over a sentence, it is about how fast you actually read and understand the sentence. If you have an eye for detail and can read fast, you will be able to finish the review faster. Whereas, if you typically don’t have enough time for review, you may outsource medical record review services to a reliable provider.
By following the techniques discussed above, you will be able to ensure high accuracy, clarity, systematic arrangement, or records and speed up the entire medical record review process. However, most attorneys find it a tedious and time-consuming task that drains a lot of their energy.
As attorneys usually remain busy with a whole lot of other significant responsibilities, many of them outsource including document review. At Cogneesol, we are a globally trusted litigation support services firm providing a wide variety of services including, legal coding/indexing, drafting motions and pleadings, subrogation, deposition summary, case summary, and many more.
As a team of qualified, skilled, and legal professionals, we possess vast experience in helping our client attorneys and law firms from across the globe prepare a strong litigation case that increases the possibility of winning the case.
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