Importance of accurate documentation in personal injury cases

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Importance of Accurate Documentation in Personal Injury Cases Accuracy is vital in legal and medical documentation.

Medical records should clearly reflect the evaluation and treatment of the patient and be consistent with the right levels of care.

Accuracy and attention to detail is paramount in any type of documentation, especially with regard to legal and medical documentation. The medical records of a patient should clearly reflect the evaluation and treatment of the patient and must be consistent with the appropriate levels of care. Many healthcare providers do not seem to attach the due importance to accuracy and detail in their clinical notes. It is important to understand that clinical documentation serves many purposes such as the following: • To ensure the appropriate level of care to the patient • To offer protection in case there is a medical malpractice or personal injury litigation • To improve communication with other providers and healthcare professionals • To standardize clinical documentation for research purposes • To obtain the correct reimbursement from payers http://www.mosmedicalrecordreview.com/

1-800-670-2809

http://www.mosmedicalrecordreview.com/

1-800-670-2809

Loopholes in Documentation Let us consider the chiropractic profession. A professional chiropractor would ensure that the initial entry in a patient record would include a detailed case history with clear documentation as regards past history, examination of symptoms, family history, surgeries undergone, previous and current medication and such important details. The medical records should be comprehensive and highlight the care, treatment and interaction with the patient.

Many chiropractors fail to document active care which is very important with regard to the treatment provided to the patient. It is proved by recent studies that chiropractic works best when it is combined with rehabilitation exercises. Active care must be started within the initial 4 – 6 weeks of treatment, and this documentation is required by insurers.

In personal injury cases, it is important to ensure that the patient has a definitive treatment plan outlining the duration, expected results and the treatment objectives. It is important to be highly specific about the exercises that are recommended and being performed by the patient. This is important from the point of view of determining how many times the patient has performed a specific exercise, and decide whether it is time for him/her to move to the next step in the treatment protocol. Active care and rehabilitation exercises are given thrice the value of passive care such as electric muscle stimulation, traction or ultrasound.

Points to Note with Regard to Documentation http://www.mosmedicalrecordreview.com/

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• Clear-cut classification of treatments as “prolonged” and “intensive.”

• Note down home exercise recommendations • Write down all verbal instructions given to a patient • Bed rest is considered active treatment since it requires the active participation of the patient.

Therefore it is important to note this down in the patient record.

Documenting rehab can be really challenging, nevertheless it is something that has to be done with extreme care and caution. It should be done in such a way that it is clear enough to the attorney or adjuster and facilitate speedy processing.

Medical records are an important factor with regard to personal injury cases. Attorneys handling PI litigation will need to review the relevant medical records and obtain a concise medical history and summary to understand the various aspects of a case. A detailed medical chronology will help them to understand the sequence of medical encounters. A medical record review company can assist attorneys with complete medical review services. Reliable services will help attorneys save considerable time, effort and expenses while also ensuring that they prepare the case well and go on to win it.

Posted by MOS Medical Record Review Company http://www.mosmedicalrecordreview.com/

http://www.mosmedicalrecordreview.com/

1-800-670-2809