Understanding EHR Entries and Medical Record Analysis

by | Published on Jul 25, 2018 | EHR/EMR

In a workers’ compensation claim, or a medical malpractice, personal injury or product liability case, the initial medical record analysis provides an overall view of the facts of the case. With most hospitals and other healthcare organizations transitioning to the electronic health record system, the service of a medical review company may prove a more cost-effective and practical option for legal and medical entities. Primarily meant for recording patient information, the EHR contains valuable evidence regarding the services provided to patients, which is important from the point of view of third-party audits. All information contained within the EHR has legal value.

What information does the EHR contain and how is this entered in the EHR?

  • In a hospital setting, the initial information is entered typically by nursing personnel in the treatment room. Patient details entered in the EHR include medical history, vital signs, allergies, current medications, and immunizations.
  • The next three sections of the electronic health record are typically entered by the physician:
    • Chief complaint or purpose and scope of the visit
    • Healthcare personal information (HPI)
    • Review of systems (ROS)

    The HPI and ROS are audited by insurers for compliance.

  • Physical examination: The findings of the physical exam for each body system are entered in this section.
  • Medical decision making or MDM: This is a very important section that contains documentation of imaging and lab tests, and a summary of the care provided during the visit. The last entries are the differential diagnosis, medical diagnosis, treatment or referral plan, and the condition and disposition of the patient at the time of discharge.

A medical review expert would first collect all the relevant medical records from all sources.

  • The first thing to ensure is that the records collected are of the right patient, and that a proper release of healthcare information is signed to ensure HIPAA compliance.
  • The next big responsibility is to verify that all the medical records are available. It is important to get a copy of any medical records the patient has collected in the course of the treatment.
  • A timeline of events (as reported by the patient) must be constructed regarding the time, place, persons tests, treatments/surgery and so on.
  • Request a complete set of medical records from the providers before starting the medical record review process.
  • Study the medical records to identify changed information, if any, and carefully analyze the timelines. See whether the events are correlated, and whether any event that should have occurred didn’t, such as whether a test that should have been performed before a certain procedure was done or not.
  • Look for care provided, omissions if any, providers present, and providers absent.
  • Review the surgical reports and discharge summary and look for discrepancies with other EHR notes. Study the nursing notes and pharmacy orders to spot any discrepancy with the physician’s notes.
  • The above steps will help you determine whether the available medical evidence supports the injury claim. The information will also enable you to decide whether an expert medical witness is necessary to lend the case more weight.

Medical chart reviews can be complex because of the complexity of the medical-legal issues involved and the difficulty of analyzing that. Expertise is vital to locate the medical records and then analyze and understand the medical history and facts. As a critical source of medical information for medical litigation, the review should be done by those who are experienced and familiar with the medical record components. A medical record review company can provide the service of legal nurse consultants who can identify important facts that an inexperienced person may miss and provide a comprehensive and efficient medical record analysis.

Discover our medical record review solutions and partner with us for your next case.

Related Posts

The Electronic Health Record – Its Medical and Legal Importance

The Electronic Health Record – Its Medical and Legal Importance

Whether to understand the type of care provided to the patient, for medical record review, for obtaining billing information, or for information exchange, electronic health records or EHRs are much more efficient and convenient that traditional paper records. One of...

The Electronic Health Record and Medical Negligence Concerns

The Electronic Health Record and Medical Negligence Concerns

Earlier, one of the major concerns when providing medical record review services was the illegible handwriting of physicians. The electronic health record was introduced and made mandatory with a view to improve the quality of care, reduce medical record errors, and...