Overview

A medical chart is nothing but a standardized collection of a single person’s medical data which can be accessed to gather information about the entire medical history of the individual. Medical chart reviews play a key role in a patient’s life in case of personal injury, employee benefits and medical malpractice. Health care facilities have historically collected and stored medical records, but developments in online data collection have contributed to the creation of personal health records (PHR) maintained by patients themselves, mostly on websites of third parties. This idea is endorsed by US national health administration entities and AHIMA, the American Health Information Management Association.

What is a medical chart?

A medical chart is a collection of valuable clinical and legal information about a patient since childbirth. It is documented by a physician, nurse, lab technician or any other member of a patient’s healthcare team. It comprises of key clinical data such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.

Different types of medical chart reviews:

There are various kinds of medical chart reviews and the reviews are carried out by qualified and skilled experts in the same way.

Chart review for medical need:

This method of analysis is used by health providers and hospital agencies to hold rates low and assess the appropriateness of treatment. Pre-authorizations and concurrent hospitalization evaluations are the most frequent forms of reviews to assess patient needs, often carried out as part of a use control policy. Applications for non-urgent programs must be completed before they are submitted for authorization. A licensed physician typically reviews claims for facilities that are not provided by a member’s package and those that are not straightforward. Simultaneous assessments carried out after the hospitalization of the patient are aimed at assessing the planned duration of stay, evaluating whether medically necessary continuing hospitalization is required, and make sure the right quality of treatment is being provided. Medical chart reviews are carried out on both sides from the insurance company and also by the hospitals which are mostly qualified physicians. It is mainly done to prevent the payment denial of the concerned individual.

Chart review for legal purposes:           

Lawyers and judges require evidence from a specialist in medico-legal proceedings concerning medical diagnosis and treatment, whether medical care given was sufficient, whether there was medical neglect or a compromise in medical standards. These examinations are usually performed by an expert medical review panel employed by the prosecutor or defense counsel. Both the necessary patient reports and other documents are checked by the team and a statement on the medical treatment rendered is prepared.

Chart review for employee benefits and disability claims:

An accident or injury occurred while working for the private or public sector it has to be evaluated and the claim is approved by the insurance company. In this scenario, chart review is intended to include a medical perspective on the injury of the worker and how it limits him/her from fulfilling their customary duties. When an employee on the job is injured even if they are treated by their doctors, it is the insurer who decides whether the claim is valid or not. If the claim is found to be genuine the insurers may not use a physician service. When the claim exceeds a certain limit the insurers render the service of a physician who is in no way connected to the injured worker. An assessment on different aspects of the condition and the impact on the length of impairment of the worker and the ability to return to work must be given by the evaluating expert or medical review committee. The causality of the damage to the applicant should be made clear. Apart from chart evaluations, an IME (Independent Medical Test) can also be used by insurers for the disability claim assessment.

Chart review for clinical documentation:       

These reviews are mainly done to ease corrections in the documentation process before a claim is filed with the insurer. Clinical Documentation Improvement (CDI) involves healthcare experts and they have to collaborate with a coding team for the best outcomes. Some hospitals have doctors or suppliers providing CDI or doctor advisory programs to examine difficult conditions.

Chart reviews for insurance support:                 

Such reviews are mostly carried out to determine how long a person is likely to live and what the risk of death is from medical complications. And in case if there is any change in the policy details it will assist with determining the insurance premiums.

What kind of data does a medical chart contain?

A medical chart contains the records of all medical events that occurred in the lifecycle of the patient. It should provide every clinician with an understanding of all that has happened to the patient before including major and minor diseases, illness, and surgeries. It includes

  • Surgical history (e.g., date of operation, operative notes)
  • Obstetric history: (e.g., pregnancy, pregnancy-induced complications, and pregnancy outcomes)
  • Medications and medical allergies
  • Family History (e.g., immediate family member health status, cause of death, common family diseases)
  • Social History (e.g., community support, close relationships, past and current occupation)
  • Habits (e.g., alcohol consumption, smoking, exercise, dietary habits, sexual history)
  • Immunization Records (e.g., vaccinations, immunoglobulin test)
  • Developmental History (e.g., baby’s growth chart, cognitive/intellectual development, motor development, social-emotional development, language development)
  • Demographics (e.g., age, religion, occupation, race, contact information)
  • Medical encounters (e.g., hospital admissions, specialist consultations, routine check-ups)

Importance of medical chart reviews

During a medical encounter, a medical chart is mandatorily reviewed to know the patient history and present health condition of the injured person. Only by knowing previous medical history, proper treatment can be provided. It also includes

  • Chief complaint
  • History of the present illness
  • Physical examination (e.g., vital signs, muscle power, organ system examinations)
  • Assessment and plan (e.g., diagnosis, treatment).
  • Orders and prescriptions
  • Progress notes
  • Test results (e.g., imaging results, pathology results, specialized testing)

Types of medical charts  

Patient-focused data can be found in both computerized and paper-based medical records. The paper-based medical record is a traditional method of recording patient data where all the pieces of information are updated manually. Currently, EHR (Electronic Health Record) is mainly used to record the patient data as it doesn’t require any additional manpower to retrieve data in written form. It is also used to analyze information in large numbers. The EHR also can support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting. An EHR also guarantees a patient’s medical chart is never lost and stored in one easy-to-access location. EHR reduces the incidence of medical error by improving the accuracy and clarity of medical records and coordination of diagnosis and treatment among health providers.

Who has access to medical charts?

A medical chart should be accessed only by the patient and the health care providers specifically interested in her or his care. The medical chart belongs to the patient, and he or she has the right to ensure that the charts are correct or to deny access to them to another person. Patients may require amendments to outdated medical charts from their physicians.

Final thoughts

To achieve a genuine insight into the patient’s medical history, a medical chart review is carried out. They have to be undertaken by qualified professionals with the requisite skills and experience. A clear analysis of the medical chart ensures reliable information and valuable assistance in the medical and legal field.