Chart review provides the documentary evidence that is vital in all personal injury litigation matters. A clear understanding of the medical facts embedded in the medical records of an injured person will help develop the argument properly. Given the significance of the medical chart and the information contained therein, attorneys and paralegals need to understand some best practices to follow during medical record analysis, so that the medical information is accurately processed. The legal team can benefit from engaging a medical professional or trained medical review team to perform the analysis of the medical chart.
What Does A Chart Review Involve?
The first step in the chart review process is medical record organization; medical records include patient history, diagnosis, clinical findings, lab results, pre- and post-operative notes, operation notes, progress notes, medications and so on. When the records are properly organized, they would provide a clear timeline of the patient’s journey from the time of injury/illness to the present date. Ideally, the review of medical records needs to be completed before or after a case is initiated. This would provide a clear view of the medical facts and help determine liability.
Before going on to the best practices for reviewing and interpreting medical records, here is a brief look at some core steps in the review process at a professional medical review firm.
- Organizing and categorizing the medical records in chronological order.
- Removing duplicate records
- All significant medical evidence is highlighted
- Details of various treatments performed, including date and procedure, as well as treatment outcomes are documented
- Identifying missing records, missing provider names
- Bookmarking to organize the records provider-wise or date-wise to facilitate easy file access
- Medical summary preparation. The summary makes it easy to review and understand various medical events.
- Hyperlinking to enable easy and instant navigation from summaries/timelines to the corresponding source records. When a reference in the hyperlinked document is clicked, it takes you to the source page.
Medical Chart Review Best Practices
Now, for the medical chart review best practices, as recommended by medicalandlifecare.com.
- Have a Clear Understanding of the Information you are Looking for and How it Enters the Medical Chart: In a patient’s medical chart, data is entered by various healthcare providers – physicians, nurses, lab technicians, physical therapists, and other healthcare professionals in the caregiving team. In an accident or injury case, the records to review would include those from the scene of accident or injury to the present time. Here, medical records would comprise those of the emergency medical team that arrives on the scene, ER records, in-patient acute hospital records, rehabilitation hospital records, outpatient care and physician visit records. Each consultation with a medical professional would include records related to the following:
- Chief complaint
- Physical exam
- History of present illness
- Evaluation and plan
- Lab/radiological orders
- Progress notes
- Test results
Also, the information in the chart may be dictated and transcribed, handwritten, or in electronic format in the EHR.
- Ask all the Relevant Questions: When interviewing the client, the legal team should ask questions regarding prior injuries or illnesses, prior and current treatments, medications and so on. This is vital to understand the patient’s health history. You get to know whether there are other illnesses or health conditions and when they may have started, current medications, past medications, and also understand other facts that may factor into how the person is healing.
- Identify Gaps in the Medical Chart: For the medical record review and chronology to be efficient, the patient story must be complete. Any gaps in the information available or missing medical records indicate an incomplete story. To fill the gaps, you need to understand what you are looking for in the first place, and who enters each information into the chart.
- Consider the Effectiveness of Treatment Provided: Any treatment plan has the objective of healing the injured/ill person, and help her rehabilitate and recover. Keeping this in mind, you need to understand whether the various interventions and treatments, and medications prescribed are effective. Ask whether the patient is still having the same problems or if new concerns have developed.
- Be Prepared for what you may Find: Sometimes, the review may reveal information and records that may work against your case, whether plaintiff or defense. Each issue needs to be addressed. You may also discover information that works in your favor and even change your case’s direction. To have a complete understanding of the information gained, it is best to retain a medical expert who understands the nuances of patient care and medical treatments.
- Organize all Information by Date and Item: This is vital because it gives a clear chronology of events. The objective is to reconstruct a detailed story that will reinforce your understanding and explanation of the individual’s experience, evaluate liability issues, and gather evidence that is critical to your case. The best practice is to begin chronicling right from the claimant’s pre-injury medical history and extend to the most recent medical record. Track and manage every request date by date and item by item, and stay organized.
- Identify any Red Flags Quickly and Understand when to Seek Expert Assistance: Time and resources are crucial for attorneys and paralegals, which makes quick decision-making indispensable. Understand when expert assistance is needed and seek a medical professional’s help to ensure accurate evaluation of the information discovered and quickly identify unusual practices, missing data, improper care/treatment, and non-compliance. Such expert opinion will strengthen the legal team with the required medical understanding of the injury or illness and the long-term complications for the claimant.
The best practices for chart review discussed above will provide a comprehensive understanding of the injury or illness of the claimant. However, teaming up with a medical expert or a professional medical review company is the sure way of understanding complex medical facts that are so important in injury litigation.