How long does it take for Medical Record Review & Analysis?

When analyzing a medical or legal claim, an accurate evaluation of the related medical records is crucial. Medical record review and analysis play a key role in a patient’s life when they encounter a medical event.  

It helps attorneys and litigators handle employee benefits, medical malpractice, insurance underwriting, personal injury, product liability, and social security disability claims.

As one of the renowned medical chart review companies, LezDo TechMed offers tailored medical record review for attorneys, law firms, and insurance companies in medical-legal claims.

Keep reading further to get more insights into the process of maintaining medical records and doing clinical chart reviews.

What is a Medical Record?

A medical record is a collection of valuable clinical and legal information about a patient since birth. Documentation may be carried out by a physician, nurse, lab technician, or any other member of a patient’s healthcare team.  

It comprises 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.

In the case of a medical emergency, the medical chart provides detailed knowledge about the medical condition and helps physicians to come up with proper treatment accordingly.

Guidelines for Medical Record Management

It is important for the doctor or medical establishment to properly maintain medical charts, since it’s a storehouse of a patient’s vital medical information. The following are the basic guidelines for medical record management.

• The clinical records should be periodically updated.

• Records should be cross-checked to avoid any false entry of medical data.

• Constant revision of outdated medical data should be done.

• Inactive medical charts in which the patient is found not to be alive should be stored separately.

• Record retention must be carried out properly.

• Unwanted records should be disposed of periodically.

• The active and inactive medical charts should be sorted out accordingly.

Problems in Medical Record Management

In paper documentation, there is an increased chance of damage due to the age of the paper, which weakens the quality, altering the color, formation of dust, which leads to insect attack and fungi formation. In case of a fire breakout or water leakage, it poses a high risk to the records.

Computerized documentation holds less risk compared to paper documentation. However, even in digital methods, errors such as double-entry, missing data, errors in patient information, etc., occur.

Need for Medical Record Review and Analysis

To exhibit the medical reports for any medico-legal purpose, an expert with a medical background should review them.  The process of extracting relevant medical data from a voluminous medical record is called medical record review or medical chart review.

Physicians medical record reviews for healthcare systems are vital for maintaining the quality of patient care. Medical record chart analysis has a major function when it comes to medical and legal claims. As the medical charts are periodically updated with patients’ up-to-date medical information, there is no room for factual error.

When a medical claim is made, going through the entire medical chart would be tedious and time-consuming. In this scenario, a proper medical record review and analysis help attorneys reach an easier and genuine conclusion.

Since medical reports provide detailed information about the patient, they act as factual evidence in lawsuits for personal injury, medical negligence, workers’ compensation, etc.

Medical chart analysis is also used by hospitals and other healthcare systems to detect cases of risk to patients, ensure clinical improvement, and hence increase patient safety.

Preparation for Medical Record Review Process

Reviewing medical records for attorneys and insurance firms could be done by the concerned party itself, or a reliable medical record review company could be hired.

If the patient is claiming the record himself, then they are bound to submit a personal request to their physicians regarding the medical file review. In that case, appropriate staff communication and review should be planned. It must be ensured that a visible patient signature is used, and whether the documentation is carried out using paper or electronic health records.

As reaching out to the staff in charge and regularly clinging to the documentation process is found to be tedious, authorized medical chart review services could be engaged in the process of analyzing medical records. Medical record review companies do the review of medical records with high precision and accuracy within a short time.

Medical record review for insurance companies is an inseparable part of the claim validation process. Getting a precise summary of medical records in less time can speed up their process.

Steps in Medical Record Review and Analysis

How to review medical records? Knowing the medical record analysis process thoroughly will help the medical chart reviewer perform it effortlessly. Only qualified clinical claims reviewers are entitled to the medical chart reviewing process.

They grasp all the complex information in the documents well and ensure that they are extracted and addressed in the medical records summary. Various steps in the medical legal medical records chart analysis include

• Retrieving the medical records

• Record sorting and organization

• Data analysis and interpretation

• Creating patient timeline/chronology

• Developing medical record summaries

• Identifying  missing data

In any medical records review process, the data collected should be properly cross-checked and clarified with a previous medical update given by the physician. Processing medical documents calls for experience and expertise on the part of medical document reviewers.

Turn Around Time (TAT) for a Medical Record Review

TAT refers to the time taken by a medical record review company to review medical records for any medical or legal purpose. How long does it take a medical expert to review a case? Usually, within 48 hours of the submission of medical records, a medical expert can complete the medical records review. However, the time frame required to complete the medical records analysis depends upon three variables.

Readability of the Medical Chart:

Medical records, as mentioned earlier, may either be in paper documents or electronic versions. Some records may not be in a readable format due to poor photocopying or poor handwriting. Medical records may also be comprised of shorthand, like abbreviations, acronyms, and medical codes, which represent the medical terms and treatment strategies.

Reviewing such documents may be more time-consuming as the reviewing expert has to accurately interpret the record without losing any valid data.  

Complexity of the Medical Chart:

Do you know that the complexity of content can affect the legal document review pages per hour? In some cases, the medical record of the patient would be highly complicated, involving too many medical procedures and services. The number of pages in the medical record would reflect the time taken for the medical legal case review process.

Expertise of the Medical Record Reviewer:

TAT for a physician chart review would also rely on the expertise of the medical records reviewer. The process of medical chart reviews demands clinical knowledge, which may be lacking in legal or paralegal staff handling litigation. In contrast, companies that operate medical review charts as a team of experienced legal nurse consultants. This would definitely speed up the medical review process.

By following the steps in the medical documentation process, expert medical professionals can collect, record, and manage patient data to support high-quality care delivery and decision-making.

Generally, an expert medical chart review company would review a standard medical record at a rate of 50 pages per hour. Skilled medical record review consultants in such outsourcing companies would review even handwritten notes in the records at a rate of 20 pages per hour.

However, TAT may vary for medical records with bulk data or readability issues. If the particular lawsuit involves any legal deadlines, it should be promptly communicated to the medical records review company to get their expedited clinical chart review service.

Final Thoughts

A nurse chart review provides a clear picture of vital medical data of an individual in chronological order. The time taken for the medical chart review process would depend on the expertise of the nurse medical records reviewer and the nature of the medical data.

Companies skilled in medical records review for attorneys could accomplish this lengthy process quickly and efficiently. These physician medical records review services offer customized TAT for reviewing, as per the needs of the client. This aids in meeting deadlines when it comes to litigation and insurance claims.  

Undoubtedly, tailored nursing chart reviews with less TAT would definitely be an advantage in outsourcing medical record reviews. The medical review companies employ quality chart reviewer specialists to ensure the quality and accuracy of medical history reviews.

LezDo TechMed has a highly experienced team of medical file review consultants to do the medical documentation analysis. We provide invaluable medical record review services at affordable rates among all medical records review companies in the U.S. We provide medical record review for healthcare plans, too. Reach out to us to get a quality medical record summary on time.