Medical records analysis involves a comprehensive evaluation of the healthcare data of a patient. In other words, it constitutes collecting, reviewing, interpreting and summarizing the facts in the patient’s medical chart. This is a service provided by medical review companies and is immensely helpful for attorneys and their legal teams. The review helps identify important information contained in the medical records, which attorneys need to understand the strong and weak points of a case. Apart from this, a thorough professional review will also help identify missing medical records.
Typically, the medical records of an individual may be voluminous and held by different healthcare providers. Some of these records could be lost or even destroyed. However, lost or destroyed records may be crucial to the plaintiff’s case. At the same time, those records are important to the healthcare provider as well because they are the only evidence to show whether a particular treatment or service was provided or not. Missing records and those lost through intentional acts of negligence could prove detrimental to the provider and lead to malpractice issues.
In injury claims, missing or inadequate medical records are a major concern when it comes to a comprehensive understanding of the case – whether medical malpractice, personal injury, or product liability. It is important to understand why medical records go missing or turn up as incomplete. Here are some reasons.
- The medical record request was not properly done, or the records were not requested at all.
- There could have been an intervening injury or inconsistent medical care.
- The provider may not have promptly documented the treatment or service.
- The records may have not been released intentionally.
It is not easy for the untrained eye to ensure that the medical records received is a full set. Only with a proper understanding about what a complete set of medical records is, and what information these hold, can you know whether the medical record set is a complete one. Moreover, proper sorting of the records is vital to arrange them chronologically and identify missing records, if any. Well-organized records are vital also for the medical reviewers to carry out their work uninterruptedly. Once the medical records are in order, the attorney will closely scrutinize the organized records, also cross-referencing the times and dates at which particular events occurred to ensure that there are no loose ends or gaps.
How does one identify missing records?
- Look whether there are any timeline gaps.
- See whether provider names are included in the narrative, but there are no records from that provider in the medical record set.
- Review medical billing statements and match them to the medical record content, closely looking at the dates, descriptions, medical codes and so on to find missing links or gaps in the narrative.
- Match all medical information and the physicians mentioned – see whether the physicians are known, whether they are treating or ordering physicians.
- Review the tense used in the descriptions, whether the info is mentioned in the present or past tense.
Medical record keeping practices of healthcare facilities also have a role to play in the release of an incomplete medical record set. For instance, intensive care records may not be kept along with the patient’s main hospital records and thus may be missing from the medical record set released to the attorney. Sometimes, investigation results such as blood results from the labs may be missing from the main record set especially if they are conveyed via telephone to the ward. Clinical documentation may be absent in such instances. Records may go missing if the results are to be obtained from multiple laboratories. Sometimes, imaging records such as X-rays, CT and MRI scans may be missing from the main notes, which only a trained medical record reviewer may be able to spot. Typical records that may not find their way into the medical record set also include nursing notes, observation charts showing blood pressure, neurological observations, temperature and so on. These as well as prescription notes, which often go missing, may be very useful to understand the medical aspects of an injury case. Another common issue is that of hybrid records, i.e. handwritten and computerized records that require careful attention.
Missing medical records could pose problems in winning a claim. Some of these documents may be vital to prove negligence or liability. So, attorneys focus on obtaining a complete set of the patient’s medical records with the support of a good medical review company. Trained and experienced medical record reviewers will ensure that all missing documents are identified and any red flags identified through a comprehensive medical record review.