Medical record review refers to the comprehensive review of the entire set of medical documents related to a person, which may have to be obtained from diverse healthcare settings. Medical records include all documentation from the initial visit to the doctor to lab test reports, diagnoses, hospital reports and so on. Attorneys and mass tort law firms that deal with litigation that requires reviewing hundreds or thousands of medical records need professional and timely medical review solutions. They may choose to review the records in-house or outsource the same to a litigation support service. The latter choice is often made, considering the added value and improved efficiency they can benefit from.
Medical Record Review Needs You Can Outsource
Legal cases that involve a medical component are heavily dependent on the medical data contained in the medical records. This data is the valuable evidence attorneys need to support their argument and win the case. Obtaining this information becomes easy with the support of an experienced medical review company. Here are the different processes that attorneys and law firms can outsource.
The first step is of course, to retrieve the medical documents, which can be a tedious process and can be outsourced to a medical record retrieval company with the best effect. Retrieval is more challenging if the patient has received care from many healthcare providers in different geographic areas. Outsourcing is a more practical option because professional record retrieval services will have established relationships with most healthcare facilities, which in turn would make it easy for them to get the documents.
The Medical Chart Review Process
Once the medical records are obtained from various healthcare repositories, the first step in the medical record review process is medical record organization.
- Organizing the Medical Records: This is something to be done before the required medical information can be extracted from the medical records. This process is often difficult because of the large-volume records made available in an unorganized manner.
- In this step, the medical records are chronologically organized to ensure clarity regarding the timeline and the correct sequence of medical encounters.
- The dates, procedures, treatment, results, and all other important data are correctly captured.
- Critical medical events are highlighted.
- Missing records are identified. A list is created of these records that are to be retrieved.
- Duplicate records are deleted, and a log is created of the same.
- Bates numbering is done for a permanent record.
- Preparing Medical Case Chronology: This is an accurate timeline of all medical encounters starting from the time of injury to the time of discharge. A chronology is very significant in medical litigation, and helps the attorney understand the sequence of medical events. It will contain key information such as the date of a medical service, time of service, source medical records, care provided and other important facts. A good chronology enables the attorney to determine whether sufficient evidence is available that is acceptable in the courtroom. It also helps the attorney have a clear understanding of the injury, causation, severity of damage, and whether the damage claimed is related to causation.
- Medical Case History and Summary: The medical case history will contain all the details regarding the plaintiff’s illness or injury, and how it was managed. The summary will contain a brief and clear description of the injury or illness, and the emergency care provided both at the scene of the event and in the emergency room. Other details included are details of hospital stay, diagnostic tests and their results, and the treatments provided. The summary will also have the treating physician’s remarks on causation, prognosis and permanency. These summaries help attorneys quickly review critical and at the same time complex medical data. They can identify any treatment inconsistencies.
The Value of Outsourced Medical Review services
Given the challenge involved in each of the above-mentioned processes, outsourced medical record review services are valuable to attorneys and their legal teams. Medical review companies make sure that the records are complete and free of errors, and that the complex medical data is made simpler for everyone to understand. By categorizing the records into different types such as progress notes, nursing records, operative records and so on, they make it easy for legal professionals to read and understand the medical content. When the medical records are well-organized and summarized, they set the tone of the case. The accurate and succinct summaries created help identify treatment inconsistencies and better resolution of medical claims.
Accurate outsourced medical review services help attorneys determine the eligibility of the case and thereby estimate the value of the case. The medical case summaries made available provide them with a clear and sequential understanding of the minor as well as major medical events involved. In this way, they help them ascertain the liability of the defendant, and the nature and extent of the damages.