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What to Look for in Medical Records

What to Look for in Medical RecordsYou have a pile of medical records pertaining to a particular case and you need to extract the required relevant information to set about preparing the case. When undertaking medical record review, there are certain crucial points you must keep in mind regarding medical records.

Are the records complete in every respect?

You have to be sure that the records are complete, and have all the necessary information regarding the various medical encounters, service providers and other details. You must also look carefully for any missing medical record that may contain valuable information.

Is the information accurate?

This is a serious aspect indeed. Medical record analysis and review is made on the assumption that the given information is accurate. Consider whether there are ambiguities in the data provided. All information has to be reliable and uncorrupted. Consistency is thus an important characteristic of a medical record. Inconsistencies can prove to be really problematic.

Is there continuity in the records?

Continuity or smooth flow of information is important with regard to accurate medical review. If there are breaks or lack of continuity in the records, a fair analysis would be virtually impossible.

Is the information provided current?

It is important that patient records give you current or real time information. If you find that the provider has failed to maintain timeliness in the healthcare records of a patient, especially in bad outcome cases, you must scrutinize the records for remarks or statements that may have been included to exonerate the wrongdoer.

If you are inexperienced in the medical field, you may miss out on crucial aspects that decide the reliability of a medical record. This calls for more conscientiousness and scrutiny on your part. Medical review companies experienced in providing value-added medical record review services can be of assistance to attorneys and paralegals preparing for medical litigation. A reliable firm will help them clearly understand which medical records are necessary as well as the advantages of having those records.

About Julie Clements

Julie Clements

With some background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort; Julie joined MOS in March of 2008. Hired for sales and support, Julie has proven capable across multiple product lines and in early 2011 was promoted to supervise all solutions managers.