What is a Medical Record Review 

The medical record is a fine collection of one’s medical diagnoses and treatment details. To precise, a valid medical record will contain a patient’s health status, social status, occupational history, financial status and so on. Hence the importance of medical records is immeasurable in Medical-legal and insurance sector.

Reviewing and analyzing a medical record is one of the vital processes in a medical-legal environment. In a personal injury claim, medical record review helps the attorneys to extract the strengths and weakness of the case. Moreover, a medical record is a piece of evidence containing the accident history, injury data, diagnosis history as well as treatment history.

A medical chart review also helps the life insurance underwriters to determine the eligibility and premium of the applicant.  For calculating the life expectancy of the applicant, it is important to review medical records.

How to Review Medical Records?

Usually, medical records are voluminous, and it needs an expert to investigate. To review medical records, it is mandatory for the medical record review expert to have soft skills and subject knowledge.

Generally, medical record review companies follow the below process model:

  1. Medical Records Retrieval: The law firm or insurance firm retrieves the medical records from treating healthcare provider with a valid HIPAA authorization from the applicant/claimant.
  2. Medical Record Analysis and Review: A physician or a legal nurse reviewer will conduct review of medical records in an unbiased and factual manner.
  3. Medical Record Summarization: After the proper analysis, a précised summary will be drafted out of the voluminous record in a specified summary format.
  4. Drafting of Special reports or Timelines: In addition to the medical record summary, supporting special reports and timeline representations can be made for better understanding of the facts.
  5. Creating Navigational Properties: For quick and easy navigation, Hyperlinks or Bookmarks will be created. This helps the reader to switch between the summary and the source record very quickly.
  6. Quality Audit of the Medical Record Summary: A team of quality controllers will double-check the final products along with the source records. Multilevel quality audits help to prevent human errors in the medical record review report.
  7. Delivering the Final Products: A set of quality checked final products will be delivered back to the client through a secured tunnel.

Now you would have understood that the medical record review process comprises of art, medical science and obviously technical oriented elements.

Well! Here is the list of 10 proven techniques one must follow to review medical records. Hopefully, it would enhance your insight about the review of medical charts.

1. Understand medical and legal terminologies

Usually, medical records will not contain the words in its common usage. For instance, “Heart attack” is the common word people use to refer to heart ailments. However, in medical records, “Myocardial Infarction” or “Acute Coronary Syndrome” is the term for diagnoses used by the healthcare providers.

Now your brain may knock you. Is knowledge in medical terminologies enough to review medical records?

No. You should have in-depth knowledge on the terminologies and its impacts. If you consider the above example, you may already be aware of what is Myocardial Infarction, but this alone will not help you. You must also know the causes, diagnostic studies, the standard of care, treatment options, and complications and so on. Also, you should know how to filter only the relevant content from medical records.

To review medical records, the individual should have an expertise in medical and legal aspects. A medical or paramedical professional with hands-on experience in a clinical setting can understand and interpret medical records way better than the non-clinical staffs. Gaining knowledge on legal jargons is also crucial to work with Medical-legal Industry.

2. Know the components of the medical record and its placements

As you know, medical records are a collection of various type of reports. Understanding each component in the voluminous record is another skill required to review medical records.

For example, a patient’s visit to Emergency Room will yield a set of records which may contain, EMS report, Physician note, Nurses Note, Triage note, Radiology reports and laboratory reports. Quick identification of each type of the report is the skill of an expert medical record reviewer.

Following are the type of reports you may frequently encounter in medical charts.

  • Physician notes
  • Nurses record
  • Operative reports and Anesthesia reports
  • Therapist notes
  • Radiology reports
  • Prescription orders
  • Hospital bills and Insurance Claim forms
  • Consent forms
  • Authorization requests
  • Correspondence notes
  • Laboratory reports
  • Ambulance reports/Paramedic reports
  • Accident reports

A skilful medical record reviewer will never miss out any of the pertinent components of a medical record. A nurse or a physician who has enough exposure to medical records in their daily routines can become a medical record review expert.

Here is how a medical record looks like.

3. Scrutinize your skillset

Hey, to read this blog post, I bet you’re from a Med-Legal background. Well, let’s talk about the skill set required for a good medical chart reviewer.

Typing Skill:

Reading and writing are the fundamental skills everyone requires to perform any type of tasks. Especially when you work on a computer-based applications, you would need typing skills as well. Typing at a great typing speed without any error  is vital to review medical records. Check your typing speed and accuracy here…

Speed Reading Skill:

Speed reading is another skill most of us are least bothered about. As a child, you would have read Apple as A.P.P.L.E but as u grew up, you should have read as Apple (Yeah, you read that right!!). This works based on how fast your eyeballs move on from one word to another. Hence practicing speed reading can make the reviewer efficient thereby helping him to review medical records more efficiently. Check your reading speed here…

4. Validate demographic data

So far, I have discussed the skills required to review medical records effectively. And from now on I am going to point out how to dig deep into the medical records.

Before jumping in to the medical record reviewing process, we need to validate some demographic data. This is done to verify if we are working on the right patient record. Validate the entire record using the name, DOB and SSN. This will prevent you from entering another person’s information.

5. Indexing medical records

Medical Record Indexing is nothing but date wise entering of the list of events. Medical record indexing is one of the best practices I have seen but only very few are following. There are some benefits that can be achieved by proper medical record indexing before processing the medical record.

Benefits of Medical Record Indexing:

  • Easy organizing and sorting of medical records
  • Identifying missing medical records
  • Extracting the duplicate pages from medical chart
  • Calculating the estimated production hours to review medical records
  • Extracting the non-workable pages from medical chart

6. Understand the real events and fact-oriented details

In any type of med-legal case, you can witness one event triggered by another. To review medical records, following and understanding the sequence of events is necessary. As a medical record analyst, you should check the facts and fetch those details into your summary. You can even highlight the important information that is vital for the case.

For an example, if you are analyzing a motor vehicle accident case, You should note the speed of the vehicle, type of collision, area of impact, people involved, vehicle involved, vehicle damage, people injured and even the minor details in police report and EMS reports. Without proper understanding of the scenario and the accident history you cannot move forward.

While reviewing inpatient medical record and emergency medical record, you should be extra cautious not to miss even a minor event. Missing such information may negatively impact the case.

7. In line with the type of output summary

You may be aware that all medical record summaries are not of the same type. There are different kinds of medical record summary outputs based on the requirement. Whichever the format you’re working on, you should be in line with the same summary format till the end.

Some of the most common types of summary formats are:

Medical Chronology

A well-organized Medical Chronology is a summary of healthcare events detailed in a timeline manner. The process of drafting a good medical chronology involves understanding and reading through the pages of medical records to focus key points, interpretation, the disease progresses, diagnostics and other  information.

Narrative Summary

A well-driven Medical Narrative Summary is a running note of plaintiff’s medical history in a narrative manner. The process highlights narrating the medical events detailed in the medical records.

Deposition Summary

A deposition summary is typically an objective, concise clerical digest of the key points of a deposition transcript. This summary identifies important points in the deposition by page and line. For litigation, it stands out to be one of the most important tools.

Demand Letter

Demand Letter sets out to the insurance company with strongest arguments related to: why the insurance company’s insured is at fault for the claimant’s injuries; the nature and extent of the injuries suffered by the claimant; the details of all medical therapies received by the claimant; details of the loss of income, claimant’s “suffering and pain” and other subjective losses.

8. Accurate interpretation of medical short-hands

Even in this digital era, we could see a handful of handwritten medical records here and there. In handwritten files, physicians use shorthands to save their time in documentation.

As a medical analyst analyzes medical records, this comes as one of the challenges. An expert medical record reviewer can crack them down easily as she/he may be aware of the shorthands from their clinical experience.

sample of medical short-hands and interpretation

Have a look at the above references for shorthands and its interpretations.

9. Proper handling of illegible records

The reasons for illegible copies may be poor penmanship of  the physician or poor photocopy of the records.

Interpreting and analyzing these kind of illegible records are quite challenging. It needs some expert level of review knowledge and vast experience in medical record reviewing.

The main challenge here is not to misinterpret the information. For example, in a mass tort case, the dosage of Pantoprazole is seen as 4 mg (actually a zero missed out due to the poor photocopy); if you are expert with hands-on experience, you will know that it is 40 mg and there is no 4 mg dose available in Pantoprazole.

Tips to improve your handwritten medical record interpretation:

  • Review clear and printed copy of records first
  • Use widely available internet resources to cross-check and validate.
  • Analyze the handwriting pattern of the physician and apply this to similar areas.
  • Never misinterpret by mere assumption
  • Summarize only the confirmed and verified information
  • Validate the information with available, clear printed copies

10. Identify any missing medical records

The phrase “Missing record” means missing of any sort of reports such as any visits, radiology reports or any pertinent information from the received medical record.

Identifying missing records is sometimes tricky and you should cross-check with multiple factors. Most of the times, missing records will spin the case scenario upside-down. Hence, fetching back the missing record is essential to review medical records without losing any vital data.

Making note of  the details of missing records with respect to dates and provider names can help the attorney/life insurance firms to retrieve the missing records.

Final Thoughts

Following this blog, I hope you could conceptualize how to read and interpret and review medical records.

Legal medical record review plays important role in Personal injury, Mass tort and Medical malpractice lawsuits. Obviously, there are challenges in reviewing medical records when done by a non-medical person. However, a  legal nurse reviewer or a physician can approach the medical chart review in a professional way!

No doubt, outsourcing your legal medical record summarization tasks to one of the reputed medical record review companies will certainly help you to save significant cost and time.