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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 have a medical encounter. It helps the attorney and the litigator deal with employee benefits, medical malpractice, insurance underwriting, personal injury, product liability, and social security disability cases.
Keep reading further to get more insights into the process of maintaining and reviewing medical records.
What is a Medical Record?
A medical record is a collection of valuable clinical and legal information about a patient since childbirth. Documentation may be carried out by a physician, nurse, lab technician, or any other member of a patient’s healthcare team. It comprises of the 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 the 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 the 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- Constant revision of outdated medical data should be done.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 if the patient is found not 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 paper which weakens the quality, altering the color, formation of dust which leads to insect attack and fungi formation. In case of fire breakout or water leakage, it poses a high risk to the records.
Computerized documentation holds less risk compared to paper documentation. However, a certain error occurs even in digital methods namely double entry, missing of data, errors in patient information, etc.
Need for Medical Record Review and Analysis
To exhibit the medical reports for any medico-legal purpose, an expert with medical background should review them. This process of extracting relevant medical data from a voluminous medical record is called medical record review.
Medical record analysis has a major function when it comes to medical and legal claims. As the medical charts are periodically updated with patient’s 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 helps the attorneys to 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
Medical record review 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 record 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 on 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.
Steps in Medical Record Review and Analysis
Only qualified medical record reviewers must be 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. Various steps in the medical record review and analysis include
- Retrieving the medical records
- Record sorting and organization
- Data analysis and interpretation
- Creating patient timeline/chronology
- Developing medical record summary
- Identifying missing data
In any medical records review process, the data collected is to be properly cross-checked and clarified with a previous medical update given by the physician.
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. The time frame required to complete medical record review and 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 shorthands 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.
- The Complexity of the Medical Chart:
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 review process.
- The Expertise of the Medical Record Reviewer:
TAT for a medical record review would also rely on the expertise of the medical record reviewer. The medical record review process demands clinical knowledge which may lack in legal or paralegal staff handling litigation. In contrast, companies that review medical charts operate as a team of experienced legal nurse consultants. This would definitely speed up the review process.
Generally, an expert medical chart review company would review a standard medical record at a rate of 50 pages per hour. Skilled medical professionals 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 with the medical records review company to get their expedited service.
Medical chart review reflects a clear picture of the vital medical data of an individual in chronological order. The time taken for the review process would depend upon the expertise of the reviewer and the nature of the medical data.
Companies skilled in medical chronology services could accomplish this lengthy process quickly and efficiently. These organizations offer customized TAT for reviewing, as per the needs of the client. This aids in meeting deadlines when it comes to litigations and insurance claims. Undoubtedly, tailored medical chart reviews in less TAT would definitely be an advantage in outsourcing the medical record reviews.