How Attorneys Can Overcome the Complexity of Reviewing Medical Records

by | Published on Jun 10, 2024 | Medical Record Review

Medical records can be really complex and difficult to analyze, given the intricate medical terminology and the sheer volume of records. The other day, we received a record review request from a personal injury attorney’s office. It was a case that involved potential malpractice, wherein the attorney’s client developed severe complications after a surgical procedure. The challenge in this regard was to organize and review the extensive medical documentation stretching across multiple providers and healthcare facilities. This type of review requires considerable expertise and medical knowledge, which makes professional record review services a more effective option. Many legal professionals feel that medical record analysis can be done in-house instead of having an outside agency do it for them. The fact is, this could involve more time and expenses. Moreover, it could prove lengthy and the medical data needed may not be made available at the opportune time.

However, in case you want to perform the review in-house, here are some considerations to take note of.

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Addressing the Medical Record Review Challenge

Just as any other challenging office process, medical record review can be made more efficient by adopting certain good strategies. The first requirement is to have a systematic plan listing out the information you have to collect and analyze. This is the best way to stay organized and efficient during the review process. Once this is done, you should next focus on retrieving the required medical records, which may be distributed across various healthcare facilities and medical record custodians. It is best to utilize medical record retrieval services in this regard to save valuable time and effort. A professional service provider will have a reliable system in place to collect the required documentation. For them, the retrieval process is much simpler because they typically have a good rapport with various medical record custodians.

Medical Record Review

Once the records are made available, you have the option of reviewing those in-house or hiring a medical review company. If you prefer the former option, here are some good strategies to follow.

  • Comprehensive note taking: You can note down all important details such as details of the injury or illness, diagnosis, dates of treatment, providers, treatment venues, outcome and progress, discrepancies in the entries and so on.
  • Create an accurate chronology: This is a timeline of various medical events based on the data gathered from the medical records. With this, you get the correct sequence of events. It will also throw light on gaps if any, in the medical documentation.
  • Educate your team on the latest medical advancements: This will lessen the complexity usually encountered in medical documentation. If you stay abreast of the various advancements in the medical field, it will help ensure accurate interpretation of the medical facts.
  • Get in touch with a medical expert: Being untrained in medicine, it is very likely that attorneys and their legal teams may need support from a medical person to understand complex medical terms and other aspects in the records. A medical expert or a medical review company can help by providing valuable insights that are vital to bolster your case.

Medical Record Organization and Review Strategies

You must have a well-structured system for organizing the medical records, reviewing them, and storing them properly. You can go for a good filing system for paper medical records, and utilize a reliable electronic document management software for digital records. An effective way to speed up the record review process is to use advanced technology tools. OCR or Optical Character Recognition software can be used to digitize the records and search for keywords. It is a great way to locate the specific information you are looking for and use it with the best effect.

Another important consideration is categorizing and labeling different types of data within the medical records. This will come in useful when you are developing your case by making it simpler to extract and review particular data points.

Creating a medical record summary is important to have at your fingertips all the key medical data such as diagnoses, treatments provided, inconsistencies and so on. The summary document is helpful for the attorney during the entire legal proceedings.

Throughout the retrieval and review processes, make sure to preserve the confidentiality of the sensitive patient data you are handling. For this, you need to have robust security measures in place. To avoid legal hassles related to healthcare data breach, make sure that your legal team is familiar with all applicable confidentiality and privacy regulations.

Consider Utilizing Medical Chart Review Services

Professional medical review services could prove to be a timesaver for busy attorneys, while also ensuring more efficiency and accuracy in the review process. Service providers in this field have the best personnel and tools in place to ensure optimal outcomes for their client attorneys. They employ both medical experts and documentation specialists to prepare medical review reports containing all the data that attorneys need. Importantly, the comprehensive review and expert opinions they provide could contribute to the attorney’s ability to obtain a favorable settlement for the client.

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