The medical record is key to ensuring appropriate care for the patient and favorable outcomes. Apart from that, it is also a valuable legal document in medical-legal litigation. In medical malpractice, product liability, workers’ compensation, and social security disability cases, a comprehensive medical record review helps clarify the various medical aspects involved. Medical records may include handwritten or electronic clinical notes, scanned records, emails, text messages, consent forms, oral correspondence between providers, photographs, X-rays, MRI/CAT scans, lab results, printouts from monitoring equipment, video and audio recordings and so on.
There are certain significant features of a medical record that could have an impact on medical records review.
- The Appropriateness of the Medical Records
An important consideration is whether the medical records are relevant to the case and the associated liability issue. A medical review company can help the attorney understand the benefits as well as the necessity for requesting specific medical records from healthcare providers. For the medical record analysis to be smooth and effective, the documents should be relevant to the case.
Accuracy implies preciseness and reliability of the collected data. This could be affected by various factors such as the dependability of devices and equipment used for diagnoses; the reliability of electronic systems used to gather, store, and share information; the expertise of healthcare professionals in data collection and documentation; access to prior medical records of the patient, and so on. If the records and information are inaccurate, it would compromise the quality of the review report.
- Completeness of the medical record
A complete medical record is one that contains sufficient data to identify the patient; supports the particular diagnosis; validates the treatment and services provided; clearly documents the treatment, care, and services and the results; facilitates the continuity of care among the care team. If these required data components are not documented in the medical chart, it is considered incomplete. When the chart is incomplete or if records are missing, it could affect the review process and slow it down.
- Availability or accessibility
A medical record is accessible when it is easy to retrieve the data contained therein. This accessibility can be affected if the documents are not organized properly, or are arranged in the wrong chronological order. Disorganized records make it difficult to understand the flow of information, which in turn slows down the record review process.
- Whether the data is timely
Healthcare documentation must be completed in a timely manner so that the information is current and relevant. Delay in documentation could affect the care and treatment prescribed for the patient. If there are late entries and lack of clarity regarding the timeliness of data, it could be very challenging for the reviewer. It must be ascertained whether the entries are dated, timed, and appropriately validated by the healthcare professional who is responsible for ordering, providing, or evaluating the service provided to the patient.
- Reliability of data in the medical record
It is vital for the medical record reviewer to ensure that the medical details in the record are those of the concerned patient, and that there has been no mix-up of patient records within the chart. A medical record can be considered consistent or reliable only when the veracity of the data has not been tarnished in any way, irrespective of the number of times and different ways in which the data has been retrieved.
- Legibility of the medical record
If there are handwritten records, legibility of the entries is a very important factor. If medical record entries are illegible, they could be misinterpreted and lead to legal hassles. It also makes the review process difficult.
The above 7 key features of a medical record could have an impact on medical chart review, its accuracy, and the ease with which the review is done. A reliable medical record is one that contains accurate information that helps identify the patient; and the documentation should support the diagnosis and validate the treatment provided. The medical record should be accurate, complete, well-organized, clear, legible, timely, and authentic, if it is to facilitate medical records review and make it more efficient.