A life care plan projects the future medical care a patient may need – diagnostic testing, therapy, medical examinations, surgery, rehabilitation, home modifications, durable medical equipment, home care/personal care support, future hospitalizations and so on. To prepare a comprehensive life care plan, medical chart review is an important first step. This review provides a thorough understanding of the information contained in the patient’s medical records. It is based on this information that the current and future medical and disability-associated care the patient will require throughout his/her lifetime is calculated. The life care plan prepared is a well-organized document that clearly outlines the medical and disability related treatments, medical equipment/products, long-term nursing or care at home services that the patient needs.
Medical Records Analysis for Diverse Injuries/Illnesses
As mentioned before, the data collected from the medical records is the foundation on which the life care plan is prepared. Accurate medical data helps support the life care plan and its recommendations. Medical review services can be utilized for cases including the following:
- Catastrophic injuries
- Spinal cord injuries
- Traumatic brain injuries
- Major surgical issues
- Pediatric health conditions
- Orthopedic injuries
- Obstetric and birth injuries
- Psychiatric issues
What Does Medical Record Review Involve?
- Medical record organization so that all the records are in proper order
- Indexing the records
- Bookmarking, and Bates stamping the medical records, so that the specific healthcare provider or facility from where the records are obtained is clearly indicated
- Ensuring that the medical chart is complete
- List all important details such as patient demographics, care provided, diagnostic procedures, lab tests, treatment notes
- List all the medical records, including imaging records that are reviewed
- List all missing medical records that are to be retrieved
- Prepare medical chronologies and timelines
- Prepare accurate medical case summaries
Now, let us look at the key components that will be included in a medical records summary.
A well-prepared medical record summary will be brief, precise, and highlight important points about the patient. It will include the following components.
- Hospitalization details: This section will contain all treatment programs, dates, and participation activities for the programs. If the patient received specialized care in the ICU or rehabilitation, those details will be provided. Along with this, a list of the medical records reviewed and their inclusive dates will be provided at the end of the summary.
- Surgical procedures: All surgeries performed will be included along with the date on which the surgery was performed, and the name of the surgeon. The specific procedure will be indicated along with the applicable ICD code. Other details you can find in this section are the type of anesthesia used (local or general), surgeon’s specialty, length of the procedure, and any complications involved.
- Medications: Here the various medications administered, the reason for administration, problems if any, will be included. The name of the medication, dosage, how it was administered (oral, IV, IM, catheter, sublingual), adverse reaction if any, long-term effects if any are the other details in this section. Apart from this, any history of infections, pain, treatment with psychotropic mediation if any, are also described.
- Rehabilitation programs: This section will contain all rehabilitation or transitional living programs, post-acute hospitalization, admission and discharge dates, therapies and other services provided, treatment goals, whether the goals were achieved, and discharge summary.
- Adverse reactions or complications: All complications, their dates of occurrence, duration of occurrence, and costs of treatment will be included here. Also, any recommendations the treating physician has made to reduce the possibility of a recurrence of the complication can be found in this section.
- Healthcare team: This section will identify all treating physicians, since the beginning of the disability, their names, addresses, telephone numbers, and specialties. All consulting physicians and specialists and their details will also be included.
- Current care requirements: Based on the comprehensive review of the medical chart, the levels of care required and the expected level of independence for the patient are listed clearly. Requirements include feeding program requirements, bowel program requirements, bladder program requirements, support care requirements, and medication regimen. These details are obtained from the discharge summaries from the hospital, rehabilitation program or transitional living program.
The medical records summary will be included in the narrative report that is prepared. Typically, it is written in a clear and easily comprehensible manner. A glossary may be included to assist those who may not be familiar with technical medical terminology. This is because the report may be read by both professionals and laymen, including the patient.
Review of Medical Records Serve the Following Purposes
- To Project Medical Costs: A detailed review of the records and physician consults as related to specific procedures can help project the cost of future medical treatments, and recommended future surgeries.
- To determine whether past medical bills are within the expected or reasonable range: Each service by each provider is reviewed and compared to the corresponding medical bills.
- To calculate the appropriate Medicare Set-aside Reports: This calculation is made based on the analysis of the patient’s particular medical condition, current treatment, expected future treatment, and life expectancy.
Medical chart review has an important role to play when it comes to preparing life care plans. This service is useful for life care planners, insurance professionals, and attorneys who can gain access to the medical information they need. Life care plans and cost projections prepared based on medical record analysis can be used for personal injury, workers’ compensation and medical malpractice cases that involve an injured plaintiff. An accurate review of the medical records will provide a clear understanding of the nature of the injury, related problems, and the most suitable approach to remedy or alleviate the same. Life care planners who need to develop a narrative report that supports the life care plan will find medical record review and medical case summary useful to justify the specific recommendations they have made for the patient. The review of medical records and their summarization is helpful also for insurers who can determine whether the medical cost projection is legitimate and the recommendations made are medically necessary.