12 Types of Records Retrieved by Medical Record Retrieval Services

by | Published on Apr 14, 2023 | Medical Record Review

Medical records are of prime importance in lawsuits that involve a medical component. This makes medical record retrieval services a very significant consideration for attorneys handling medical malpractice, personal injury, workers’ compensation, product liability and other medical-related cases. Only with the proper medical documentation, can the extent of an injury and its impact on the individual be clearly understood. The right medical records will help the attorney draft a good and effective demand letter that is crucial to obtain proper settlement or compensation for the plaintiff.

Medical Record Types Obtained by Medical Record Retrieval Companies

  1. Physician order sheet and prescriptions: These are written or dictated notes showing the interaction between the physician and the patient. These are prepared after an office visit, a telemedicine visit, testing, a procedure, therapy or other medical encounter. Accurate physician notes are necessary for the systematic documentation of a patient’s medical history, present illness, diagnosis, current and past medications, allergies, treatment, and overall care.
  2. Nurse’s admission sheet: An important record in nursing documentation, this admission sheet documents the patient’s status on admission, reasons for the admission, and the initial instructions for that patient’s care.
  3. Nurse’s notes: These include patient assessment, processes, intervention, and evaluation.
  4. Medical history and examination: It outlines the patient’s medical history, family medical history, social history, surgical history, allergies, and medications the patient is taking or has recently stopped taking.
  5. Emergency room notes: These notes summarize a patient’s status during an emergency department encounter. This would include both narrative and free text data, and comprises information related to evaluation and plans of care, chief complaints, physical findings, interventions and outcomes.
  6. Medication records: These notes contain details of the medications prescribed, those the patient has already been taking, and related details. Details include prescription and non-prescription medication including the dosage, method of intake, and schedule.
  7. Mental status report: This report provides the details of a mental examination, and states whether the patient is in his/her right mental abilities.
  8. Operative report: Operative or surgical reports describe the procedures, findings and outcome of a surgical operation.
  9. Anesthesia notes: These provide information regarding the type of anesthesia given, and related details.
  10. Progress notes: These records include new information and changes during patient treatment. These are written by all members in the care team, and the information included comprises observations of the patient’s physical and mental condition, changes in the patient’s condition, vital signs at certain intervals, bladder and bowel functions, food intake and so on.
  11. Radiology reports: These notes are related to the findings of imaging studies such as X-rays, MRI, scans and so on.
  12. Discharge summary: A hospital discharge summary is prepared when a patient checks out of the hospital. It gives the reasons for the hospital admission, results of the tests made, and how the patient feels after the discharge. Any medical advice provided may also be included.

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Medical records are an essential component of personal injury claims because they help establish the injuries and their impact, determine the severity of the injuries, and enable personal injury attorneys to prepare a demand letter requesting accurate compensation. However, retrieving, organizing, and reviewing the voluminous medical records can be very challenging. These jobs are best done by companies providing medical record retrieval services. Outsourcing medical record retrieval and review will make these processes more effective and efficient. Critical medical evidence is retrieved so that the cases can be got trial-ready more quickly. Moreover, law firms and attorneys also stand to benefit from reduced costs, and valuable savings in terms of money and effort.

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