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Top 10 techniques to Review Medical Records

by | Jul 5, 2024 | Medical Record Review

Handling complex legal claims requires the expertise of medical record review companies. In completing the legal needs of attorneys and law firms, LezDo TechMed’s team of medical and legal experts employ various techniques. Precision and accuracy in producing reviews and efficiency in managing scaled up volumes of records is an easy task for our team.

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How to do a medical chart review? With our decade-long experience in medical record review services, here we discuss the best way to organize medical records and how to review medical records to provide reliable medical record review for law firms and insurance companies.

What is Medical Record Review? 

What is a medical document or medical record? The medical record is a fine collection of one’s medical diagnoses and treatment details. To be precise, the components of a medical record include a patient’s health status, social status, occupational history, financial status, and so on. Hence the importance of medical records is immeasurable in the medical-legal and insurance sectors.

Typically, a medical record format is carefully designed to incorporate a variety of data types, including medical record images and various clinical record examples that detail the patient’s history, diagnoses, and treatment plans.

What is medical chart review or record review? Medical record review is reviewing and analyzing a medical record to identify the significant medical events in a patient’s life pertaining to a legal or insurance claim.

As a medical record is a piece of evidence containing the accident history, injury data, diagnosis history as well as treatment history, it is much needed to prove claims. Reviewing and analyzing a medical record is one of the vital processes in a medical-legal environment. In personal injury claims, medical records reviews help the attorneys to extract the strengths and weaknesses of the case.

LezDo TechMed provides high quality medical records review for attorneys to win claims.

Need Quality Medical Record Reviews?

There are three kinds of samples of medical records that both patients and doctors frequently use: personal medical history (PHR), digital health record (EMR) digital health record (EHR).

Legal nurse consultant reviews also help 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 records review expert to have soft skills and subject knowledge. A medical record and a review of medical records are inseparable parts of winning litigation. Reading medical records and subsequent medical record review process needs professional training.

A medical record review company offering  medical record review services for law firms follows the below process model:

  1. Medical Records Retrieval: The law firm or insurance firm retrieves the medical records from treating healthcare providers with valid HIPAA authorization from the applicant/claimant. Sometimes, even top medical records retrieval companies for lawyers assist law firms in medical record retrieval.
  2. Medical Records Analysis and Review: A physician or a legal nurse reviewer will conduct legal medical record reviews in an unbiased and factual manner.
  3. Medical Record Summarization: After the proper medical record analysis process, a medical record review summary will be drafted out of the voluminous medical report in a specified summary format. Medical records summaries help in easy understanding of the information data contained in the medical records.
  4. Drafting of Special reports or Timelines: In addition to the medical record summary, supporting special reports and timeline representations can be made for a better understanding of the facts.
  5. Creating Navigational Properties: For quick and easy navigation, after review of records, 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: After analyzing medical records, 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 of medical history review will be delivered back to the client through a secured tunnel.

Now you would have to understand that the medical report review process comprises art, medical science, and obviously technical-oriented elements.

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

1. Understand medical and legal terminologies

Usually, medical record collection will not contain the words in their 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 healthcare providers.

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

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

To do the herculean task of interpreting medical records, the individual should have 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 staff. Gaining knowledge of legal jargon is also crucial to working in Medical-legal Industry.

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

As you know, medical records are a collection of various types of reports. While processing medical documents, understanding each of the 10 components of a medical record in the voluminous record is another skill required to review medical records.

What are the components of a medical record? A patient’s visit to Emergency Room will yield a set of records that may contain an EMS report, Physician note, Nurses Note, Triage note, Radiology report, and laboratory report. Quick identification of each type of 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 skillful medical document reviewer will never miss out on 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.

sample-medical-record-with-vital-information-lezdo-techmed-how-to-review-medical-records

Here is what a medical record looks like.  Know the explained components of medical records and proceed to review.

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 task. Especially when you work on computer-based applications, you would need typing skills as well. Typing at a great typing speed without any errors 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 medical records.

Before jumping into 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 records indexing before processing the medical record. The medical records indexing services aid in creating efficient medical document reviews. In the digital era, many medical review companies offer AI medical records sorting and indexing services to quicken the process.

Benefits of Medical Record Indexing:

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

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 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 minor details in the police report and EMS reports. Without a proper understanding of the scenario and the accident history, you cannot move forward.

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

6. 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 types of medical records you’re working on, you should be in line with the same summary format till the end. This is crucial when preparing a medical summary for law firms.

The most common types of medical records summary services 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 on key points, interpretation, and the disease progresses, diagnostics, and other information.

Narrative Summary

A well-driven Medical Narrative Summary is a running note of the plaintiff’s medical history in a narrative manner. The physician chart review 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 the 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.

7. Accurate interpretation of medical short-hands

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

8. 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 kinds of illegible records or handwritten medical notes are quite challenging. It needs some expert level of review knowledge and vast experience in medical record reviewing.

The main challenge in medical records analysis 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 an 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 copies 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

9. Identify any missing medical records

The phrase “Missing record” means missing any sort of report, 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 time, missing medical 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 a 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.

10. 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.

Don’ts in Medical Records Review

Having discussed the top ten techniques to review medical records. Let us now dive into some don’ts that are to be followed in the review of medical records.

  • Never share the medical data that you encounter during medical records reviews with anyone.
  • The rationale behind medical record review and analysis is to strengthen the claim and not research or studies.
  • The medical record review report should not be biased.
  • The medical record reviewer should never miss vital medical data like clinically pertinent telephone calls, laboratory results, etc., during the medical file review.
  • The medical records reviewer should not interpret any data and conduct the medical chart review process.
  • The medical record reviewer should not delay while reviewing records for legal cases and insurance claims.

By following these “Don’ts”, medical record reviewers can ensure accuracy, clarity and confidentiality.

AI in Medical Record Review

The use of AI in reviewing medical records is a big step forward for both healthcare and legal fields. It turns a slow and detailed task into something quicker, more accurate, and easier to handle. AI helps sort through lots of medical data quickly, finding important details and patterns that reviewers might miss. This is especially useful in personal injury claims, where finding and understanding medical information fast can really affect the outcome. As AI gets better, it’s making the process of looking at medical records more focused on the needs of patients and more helpful for making decisions in healthcare and law.

Final Thoughts

Following this blog, I hope you can conceptualize how to read medical records and interpret medical data reviews.

Medical record review for attorneys plays an important role in personal injury, mass tort, and medical malpractice lawsuits. Obviously, there are challenges in reviewing medical records for attorneys when done by a non-medical person. However, a  medical record review analyst, legal nurse reviewer, or physician can approach the medical chart review in a professional way! A medical record review report prepared by expert reviewers would reflect the claimant’s damages effectively.

How long does it take a medical expert to review a case? Depending on the complexity of the case, volume of medical records, severity of injuries and number of providers involved, an expert would need five to seven days to complete the medical chart reviews. 

No doubt, outsourcing your legal medical record summarization tasks to one of the reputed medical record review companies will certainly result in precise medical record summaries. Outsourcing medical record summary services will help you save significant costs and time.

Are you searching for the best medical records review services? LezDo TechMed is one of the most reliable medical chart review companies, which handles the nursing chart reviews effectively.

Connect with LezDo TechMed and experience the essence of our medical records review samples. Whether it’s medical record review for health care plan or for legal claims, we never fail the expectations of our clients. 

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We review medical records for attorneys, paralegals, and QMEs. IMEs, etc., at the best TAT and affordable costs. Our review of the medical record process is genuine and trustworthy, which you can experience in our medical record samples. Our medical record summary services are added assets in many recent burning lawsuits in the United States.

To do an efficient documentation review medical experts with knowledge of legal matters are essential. With LezDo TechMed, one of the best medico-legal record services USA, you need not worry about that, as we have qualified experts to handle medical documentation analysis for your cases.

Our medical record review USA provides reliable services in medical record review for insurance companies and law firms, that can lay a strong foundation for your legal claims.

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