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What Does the Medical Record Organization Process Involve?

Medical Record Organization

 

Medical records review and analysis involves comprehensive evaluation of a patient’s healthcare information for medical or legal purposes. The reviewer will review, interpret, and analyze the facts in the medical chart to find crucial medical evidence important in personal injury and other cases involving medical records. Medical analysis begins with accurate medical record organization, which is vital to obtain an unambiguous and orderly health history of the patient. Medical record reviews are of prime importance to attorneys, helping them to easily understand the critical medical aspects of the cases they handle.

Typically, paralegals in a law firm are assigned the duty of requesting and understanding the content in the medical records. Needless to say, this is a tough and time-consuming job, which also demands great attention to even the minutest details. The medical records that are obtained from medical providers across different medical facilities are mostly voluminous while also disorganized and confusing. Proper organization of medical records is advantageous in the following ways:

  • You can easily determine if you have all the necessary records
  • Identify missing records
  • Identify duplicate records
  • Identify inconsistencies, if any
  • Makes medical record analysis more efficient and easier

During the medical record organization process, you must ensure the completeness of each record. An expert medical record reviewer would remove any documentation belonging to other individuals. Currently, smart technology is leveraged to create an efficient solution to organize and index medical records accurately and with ease. The medical records are organized based on categories such as document type, facilities, location and provider. Here’s a look at the sequence of steps involved.

  • Unitization: The patient records are reviewed to evaluate their logical document boundaries and grouped by physician visit, date of procedure, and so on for review purposes.
  • Consolidation: In this step, any duplicate or non-essential documentation are either segregated or removed as per the client’s preference.
  • Coding and Indexing: Important details such as dates, provider or facility names, procedures, medical record types, and so on are noted and captured for use during keyword searches. Customized indexing fields are developed in keeping with client requirements.
  • Categorization: Once the indexing results are available, the records are organized into main categories and subsections that are most convenient for review purposes.
  • Medical Record Sorting: Here each medical record category is sorted chronologically.
  • Bookmarking and Hyperlinking: The sorted, organized records are converted into PDF format with bookmarks that facilitate speedy access to particular medical record types, diagnoses, tests performed, progress notes and so on.
  • OCR: In this step, the entire medical chart or record is made text-searchable using OCR or Optical Character Recognition software.

As part of the organization process, a concise and accurate medical case summary is also prepared including important details such as date of admission, diagnosis, testing, patient case history, procedures and ultimate discharge from the healthcare facility.

Medical record organization is crucial for smooth and efficient processing of insurance claims and litigation matters. With this, a clear chronology of events, patient medical history, providers, and practices is prepared that is vital for the timely preparation and review of the medical records. A medical records review company can help with organizing the medical records so that the review process is expedited. They use proprietary web-based software for the purpose, and provide a secure and convenient way for their clients to view, access and search the medical records at any time, from anywhere. Properly organized and prepared medical records are key to maximize the potential of the case.

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