The medical records of a patient are very important for various agencies such as insurance companies and government agencies. Medical record analysis and review is crucial in medical litigation. Usually medical records are reviewed to identify the care received by the patient, deviations from prescribed standards of care, medical negligence, discrepancies, inaccurate information and so on. Attorneys reviewing the medical records need information such as:
- The specific care provided to the patient
- Why that medical care was needed
- Whether the patient was diagnosed and treated in a timely manner
- Whether the care given was appropriate
- What went wrong
- Whether there was any medical negligence involved
The medical record communicates to the attorney, providing valuable details regarding the various medical facts in a case.
However, the task of medical record review is quite challenging to a non-medical person such as a legal professional. The major roadblocks on the way to a smooth medical documentation review are the following.
- Many healthcare facilities maintain a hybrid record system with both electronic and paper medical records. Handwritten records are a real problem especially when the writing is illegible. Attorneys will find it difficult to understand details regarding the patient’s care such as who provided the specific care and who wrote what.
- Another concern is whether you received all the medical records, or whether the medical chart is complete. Many details may be missing such as relevant nursing notes, surgery reports, ER records, medication details and so on.
- Diverse charting systems also possess a real challenge. Different facilities have different ways of documentation. Reviewing such records becomes tedious for an attorney who has to handle medical records from multiple healthcare facilities.
- A major problem is that posed by EHR. Most electronic health record systems do not provide meaningful information. They fail to provide the narrative data that is very significant when dealing with a medical negligence case. The EHR software which is far from perfect in most cases creates a lot of frustration for both physicians and attorneys. When the records are printed, they emerge in random order at times which will have to be logically organized – a time-consuming proposition.
A medical record review company that offers the service of a team of professionals including physicians, registered nurses and documentation specialists can assist busy attorneys. Since they are trained and experienced in reviewing complex medical documentation, the medical record review will be completed quickly. Attorneys can have the required medical facts at their fingertips within minimal turnaround time. Moreover, they need not waste valuable hours poring over unintelligible medical documentation, unable to determine whether a case is worth defending or not.