Medical records may comprise both electronic and paper documentation, and these contain accurate information regarding the patient, the diagnosis, treatment and results. When reviewing these for legal purposes there are certain features that make an impact on the analysis.
- Ease of data retrieval: Medical records need to be properly organized to facilitate data retrieval. Any kind of mismanagement or erratic record keeping will make it difficult to have a clear understanding of the information recorded.
- Accuracy of the records: Patient records sometimes contain misleading information. A number of factors can affect the accuracy of the medical record – reliability of the diagnostic equipment, the documenting skills of healthcare professionals, the workload of physicians and other healthcare staff making the entries, access to the previous records of the patient, and the reliability of the electronic systems utilized for collecting, dispersing and storing information.
- Missing records: The medical chart has to be complete in every way. Missing records can be really frustrating during the review process.
- Timeliness: Entries in the records are to be made in a timely manner, as soon as possible after an observation is made or care provided. If the documentation is not done in a timely manner, it can have a serious impact on the treatment and care prescribed for the patient. The reviewer has to be doubly careful in scrutinizing late entries to identify self serving remarks or notes.
- Presence of inconsistent data: Reviewers have to be constantly wary of inconsistent information in the medical records. It is to be ensured that the data has not been corrupted, and that there has been no kind of mix-up whatsoever.
Medical review firms that have been serving the industry for a long time can help attorneys in the record review process. Professional reviewers take care of medical record organization and indexing. They provide concise medical case summaries that will help in understanding the case clearly.