Attorneys require collecting and reviewing of medical records to obtain crucial evidence that support their case. While the right data and information are extremely important, medical record management also comes with some challenges. Medical records that include critical evidence need to be managed well and should be easily accessible. Legal teams including paralegal staff often find it difficult to collect and effectively manage those records, because of which they prefer outsourcing the task to experienced medical review companies.
Here are some key challenges lawyers face when handling medical records –
No Standard Formatting Method
While HIPAA standards focus on the security and privacy to protect medical records and patients’ protected health information (PHI), it has nothing to do with how the records are formatted and presented. Because of this, there’s no uniformity among medical facilities and providers. The major challenge comes with handwritten records, especially if the key information required is illegible. Poor handwritten notes make it difficult for lawyers to understand the key elements of patient injuries and care provided. In such cases, law firms may have to either enlarge the page by scanning the document to try making the writing clearer or may have to consult healthcare professionals to interpret the writing. Here’s where the role of professional legal nurse consultants becomes important. Medical record review companies provide the services of skilled legal nurse consultants, as they’ll be familiar with medical jargon and terminology, and can identify such illegible content.
Issues with Electronic Medical Records (EMRs)
Often, lawyers have to deal with electronic medical records (EMRs). Even though EMRs appear legible, attorneys may not get the meaningful or complete information they require to prove the case. Loss of narrative data and missing records may keep law firms in a dilemma. Human errors are also common with EMRs. In certain cases, pre-populated data will be there, where the information needs to be copied and pasted from one history to another. If the nurses or physicians fail to copy the information correctly, relevant information will be missing in the records. This will confuse the attorneys or may lead to inaccurate data. Also, the evidence they receive from these records will be with certain limitations.
To prevent such issues, make sure to have an idea about the particular EMR programs or systems used by the specific provider or practice you are requesting records from. Also, specify the particular medical records you are requesting for any case. It would be great if the law firm could get direct access to the EMR program.
Records with Incomplete Data
At times, law firms may not receive the complete records requested, which leads to further loss of time and money. Even if the medical records received are certified copies, if some crucial notes, operative reports or any information is missing, then it cannot be used as valid evidence in court. In such cases, attorneys may have to request the complete chart again from the providers or visit the hospital directly to refer to the missing records. To avoid such issues, it is important for law firms to have an established methodology for requesting medical records. A proper medical record review helps recognize what crucial data is missing on a given record and professional record review service providers will follow up with the provider on the lawyer’s behalf and collect the necessary records.
Medical records relevant to a case may be obtained from hospitals, physicians’ practices and clinics, which is another time-consuming process. Often, paralegals have to follow certain steps to request and collect medical records such as admission information/summary, discharge summary, physician’s progress notes, consultation reports, treatment and medication sheets, nursing treatment records etc. from providers. They must make sure to send the record request to the right address and they must be specific about the records requested.
After collecting the records, it is also important to organize medical records for faster access to key points relevant for the case. Medical record organization services provided by experienced providers involve capturing important dates, procedures, treatments and other relevant data, highlighting critical events, deleting duplicate records, identifying missing records and generating a list of these, and creating summaries for a quick review.