Given the importance of medical records in a medical malpractice or personal injury case, Medical Records need to be concise and clear. Ask attorneys and you’ll find that clarity in medical records often remains a fiction. Ambiguous and confusing medical records continue to be a grave issue for many lawyers and attorneys. Incomplete medical records also pose considerable challenge.
Medical record impasses that attorneys have to deal with:
- Medical records must be complete in every way, with all information about the care provided, the place of service and provider details. This is often missing in medical records, with either the provider forgetting to document the care provided or the medical records department/provider failing to make available the record with supporting documentation. Sometimes nursing notes, some part of operative reports, physician orders, and medication administration records may be missing.
- Handwriting is a major hurdle in medical records where the entries are made by hand. Good and legible handwriting is often not the virtue of healthcare providers and usually illegible handwriting in the medical records are a grave threat to patient safety. When multiple providers are involved in care provision to a patient, it is sometimes difficult even to determine who wrote what. Often, the names themselves are incomprehensible.
- Lack of uniformity of medical records obtained from various facilities is another stumbling block. Charting may not be standardized and this can create confusion during the medical record review process.
- Even with electronic medical records, faulty design in software poses a problem. There have been reports of the records being printed out in a random manner, and have to be put in a logical order. This consumes a lot of time and effort.
- Often the complexity created by the many screens a healthcare provider have to click through to add data leads to problems such as loss in narrative data. This in turn may make it difficult to understand the medical events clearly.
A medical review company can extend that much needed helping hand to lawyers and attorneys, saving them the trouble of deciphering complex medical records. Professional medical review professionals can efficiently handle all the above and other issues related to patient records by virtue of the fact that reviewing medical records is their core task, to carry out which they have the necessary prowess, time and dedication.