How Medical Record Review Services Can Prove Advantageous to Attorneys

How Medical Record Review Services Can Prove Advantageous to Attorneys

Medical record review for attorneys focuses on extracting discoverable information from EHR that is useful for prosecuting or defending a case.

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Hospitals, physicians and other healthcare providers have to use EHR systems to record patient information, according to federal directive. From the legal point of view, all information contained within EHR is discoverable. Electronic health records are designed to receive all healthcare data of the patient from the physician, support medical coding and billing processes, ensure content uniformity and facilitate medical record review. Medical record review for attorneys focuses on extracting discoverable information from the EHR that will prove useful for the attorney prosecuting or defending a medical malpractice, workers’ compensation or auto injury case. Given the immense significance of medical evidence in the above mentioned cases, it is vital that the review and analysis of the relevant medical records is done by expert medical reviewers.

Consider the case of a patient visiting a hospital setting. EHRs receive information in the following sequence: 

On a patient’s first visit to a hospital emergency room, he/she first provides valid credentials.

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In the treatment room, nursing personnel record the patient’s medical history, vital signs, allergies, current medications and immunizations.

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The next step is the physician asking the patient about o His/her chief complaint to understand and establish the purpose of the visit. o The intensity of the problem, the time it started and so on, or questions related to HPI or healthcare personal information o Additional symptoms associated with the chief complaint (these are the ROS or review of systems questions to review each system).

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Third party payers appraise the ROS and HPI for compliance. 

The physician then examines the patient in detail and dictates the findings for each body system into the EHR.

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Following this, the results of imaging, EKG, and lab tests are entered, along with a concise description of the care provided during the visit in the EHR section that relates to MDM or medical decision making.

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The final entries in the EHR are medical diagnosis (specific causation of the illness), differential diagnosis (general causation), treatment/referral plan, and the condition and disposition of the patient when he/she leaves the hospital.

Going about the Medical Record Review Process Attorneys preparing to review the relevant medical records must first make sure that the records received are for the correct patient, and that they have been released in keeping with HIPAA mandates. In a wrongful death case, it is important to verify that a court approved estate executor has signed for the release of the records. Obtain a copy of the death certificate and supplemental certificate to understand the cause of death. Compare this to the injury claim.

The next important thing to do is to make sure that all the medical records are available. With the new electronic medical records, this can prove to be rather challenging. Unlike paper records, EHRs make little sense when simply printed out. Therefore the attorney must ask for all records including earlier paper records. The HIPAA-mandated PHI (protected health information) log will give a list of what, where, by and to whom patient medical records have been distributed. It will also provide information regarding where other copies of the patient’s

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medical records can be found. A medical record review company can help the attorney in this regard by organizing and indexing the medical records and preparing an accurate chronology.

Professional medical reviewers can also help identify changed information if any, and review the time lines. A detailed review of the time lines will help to correlate the events that occurred; in addition, it will also help find events that should have occurred but did not. For instance, did the doctor perform an allergy test before administering a medicine that was likely to cause an allergic reaction in the patient?

Other important aspects include: 

Review the medical records for the various medical events.

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Have there been any omissions or failure to provide the required care?

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Identify clearly the providers who assisted in providing care.

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Is there anyone who should have assisted but did not partake in providing care?

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Review the operative reports and discharge summary for each hospital admission to find out care discrepancies if any.

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Compare the nursing notes and pharmacy orders with the physician’s notes.

It is only by means of a detailed review that the attorney can determine whether the medical evidence supports or defends one or more cause of action at issue. The next important thing to do is to decide whether an expert witness is needed to testify, and from which specialty.

Why Consider Medical Record Review Services? 

Even if attorneys are knowledgeable in the medical and legal issues related to a claim, the sheer volume of the medical records may be too much for an attorney and his/her

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office staff to handle. Outsourcing can facilitate an initial review, medical record organization, creation of a time line and medical record summarization. Apart from saving numerous working hours for the attorney, this will also bring the benefit of having the medical records ready for review by a medical expert. 

They will ensure that the medical chart is complete and consistent. This means that the data is reliable and uncorrupted.

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The service of a reliable medical review company will help establish whether the medical records are relevant to the liability issue associated with the case. It will help the attorney understand clearly why specific medical records are necessary and what the benefits are in having them.

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