Chart Review 101 – How Is Meaningful Information Extracted From Medical Records?

by | Published on Oct 14, 2022 | Medical Record Review

Medical chart review is extremely important for attorneys litigating medico-legal cases. A medical chart documents the patient’s protected health information (PHI) since childbirth. It includes valuable clinical and legal data like the admission, discharge, and transfer (ADT) protocol assigned with a medical record number. To develop legal notes, it is essential to read charts to extract details of the plaintiff. However, comprehending the medical jargon and complex diagnoses and procedure details in medical charts is complex. Medical review companies can prepare an accurate and brief summary of the relevant medical data of the plaintiff enabling a quick reference for attorneys. Read further to know the important facts about chart review and how this process helps extract meaningful information from the medical records of a patient.

What Is a Medical Chart Review?

Medical charts are confidential documents that contain valuable clinical and legal information about the plaintiff since childbirth. Medical charts/records contain comprehensive information on demographics, vital signs, treatment plans, diagnoses, progress notes, immunization dates, and diagnostic test results among other details. This medical review is ideally performed by a medical review company that will extract and highlight all relevant medical evidence pertaining to the personal injury, workers compensation, disability, or medical malpractice case. Similarly, a medical peer review team can extract the necessary evidence for payers to make sure that payment is made only for services that meet coverage, coding and medical necessity requirements. Proper organization of the medical records and their accurate review enables attorneys to determine the strengths and weaknesses of the cases they handle and take a decision whether to pursue the case or not.

What Is the Data Stored in a Medical Chart?

  • Family history of the plaintiff which gives details like any common family illness and the health status of the family members.
  • Details of the surgery like the date of operation and operative notes of the treating physician.
  • Obstetric histories like pregnancy-related complications and pregnancy outcomes.
  • Social history of the plaintiff.
  • Habits such as alcohol consumption, exercise regime, and dietary habits.
  • Immunization records like vaccinations and immunoglobulin tests.
  • Developmental history such as baby’s growth chart and cognitive/intelligent development.
  • Medical encounters of the plaintiff.

From the above, it is understood that medical charts give authentic information on the medical journey of the plaintiff. Attorneys need to extract key information pertaining to the case to give arguments an evidentiary value.

Medical Records Review Services for Attorneys

Collecting and managing medical records is crucial from intake to discovery in medico-legal cases. The outcome of the trial process is entirely dependent upon the contents of the medical records. Attorneys have to establish the existence, cause, and seriousness of the victim’s injuries for a successful claim. Therefore, maintaining medical records holds importance regardless of the volume of the medical records. Effective management of medical records is ensured by medical review solutions.

There can be multiple medical records for each case and analyzing medical records for valid legal points can be a difficult task. These documents have to be arranged in a logical order to avoid overlooking any pertinent medical information. A medical record review company uses a guided approach to compile essential data from medical records.

Efficiently organizes the medical records

This is the initial step that is done before extracting relevant data from the medical records. The records are digitized and systematically arranged by focusing on the timeline of the medical events of the plaintiff. A medical record review company starts the task once all the medical records are received. These records are chronologically arranged and digitized for facilitating quick reference. This benefits the attorney in the following manner:

  • There will be clarity in the sequence of medical events, which enables attorneys to accurately give the date of injury and the events preceding the same.
  • The procedures, treatments, drugs administered and diagnostic results can showcase the gravity of the injury and the compensation proportional to it.
  • The critical events highlighted by the medical record review company aid attorneys to identify the areas of concern.
  • As duplicate records are deleted, attorneys find it easier to compile data that needs attention.
  • The log of events serves as the tool for framing arguments.
  • The list of missing records can be used to fetch important records related to the case.
  • Bates numbering of medical records ensures maintaining of the permanent record of plaintiffs’ lawsuits.
  • Adherence to HIPAA guidelines ensures that the confidential data of the plaintiff is protected.

Summarizes Medical Records with precision

The summary of the medical records reflects the details of the injury suffered by the plaintiff in a nutshell. It is a concise description of the accident/injury and the emergency care received by the plaintiff at the site of the event and at the ER.

  • Details such as duration of hospital stay, treatments provided, and diagnostic test results are highlighted in the medical record summary besides the clinical observations.
  • Medical record summarization enables attorneys to navigate through the key points easily.
  • Evaluation of the claim can be correctly computed.
  • Critical areas can be identified and capitalized on
  • A flawless medical record summary avoids frequent referring to each and every medical document.

Accurately Documents Medical Case Chronology

A medical case chronology gives an accurate timeline of the medical events of the plaintiff from the time of the injury to the time of injury. This simplifies the attorneys’ task of understanding the sequence of events.

  • The important points relevant to the case are extracted from the medical records.
  • The focused period of care is highlighted enabling attorneys to frame goal-oriented arguments.
  • The customized medical case chronology addresses the claimant’s compensation requirements.

Now, a look at some best practices to follow to extract relevant legal points from the medical records.

Extracting Valid Legal Points from Medical Records

To frame strong arguments to litigate the case, medical charts are to be efficiently navigated. These have to be read carefully to identify the areas that need to be highlighted and included for the preparation of the trial. Organizing legally pertinent data from the medical chart requires establishing an objective-oriented methodological system. In this way, the medical charts can be utilized to the fullest extent possible. We can discuss how it can be realized.

Focus on the purpose of the claim

Analyze the medical charts to identify key elements that can serve as evidence for the claims demanded. Some facts that can be sorted from the huge volume of data are the date of the injury, diagnostic test results, and treatment history besides the physician’s prognosis. The diagnoses must be learned to link it to the demands for eligible compensation for the injury. Conduct basic research and develop the case around the findings.

Follow best practices to decipher medical abbreviations and terminologies

Medical terminologies and abbreviations are valuable sources of information that can answer several questions regarding the lawsuit. Attorneys are unfamiliar with these complex medical terms and have to conduct research to understand them. Identify the terms and abbreviations relevant to the case. Gather patient education materials published for the condition mentioned in the medical charts. These resources are more easily understandable to the general public. Evaluate these resources and prepare for the trial process by focusing on the critical areas of concern. This can also assist attorneys to check whether there was any breach of the standard of care. The research should be based on authoritative literature texts.

Make use of software systems to streamline the medical chart review process

Time is an important factor in a medico-legal case. Therefore, it is crucial to complete trial preparation within the stipulated time. In such demanding circumstances, utilize software systems for optical character recognition. This can enable the recognition of text within the image documents which particularly aims at identifying the physician notes embedded in scan reports. It ensures that different tasks associated with the completion of the trial process finishes in tandem. Attorneys might have to juggle many medical records and tracing information with the help of text converting software can increase the rate at which information is compiled.

A medical chart review assists attorneys in understanding the complete medical history of the plaintiff. It can contribute to the attorney’s assessment of the reason for filing the lawsuit. Providers of medical review solutions have the expertise to efficiently read through the medical charts for legal purposes. It can ensure that the complete attention of attorneys is on developing the merits of the case for a successful outcome.

Discover our medical record review solutions and partner with us for your next case.

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