Medical Record Features That Could Impact Medical Record Review

Medical Record Features That Could Impact Medical Record Review

Medical records are important not only to ensure appropriate care for the patient, but are also valuable legal documents in medical-legal litigation. Comprehensive medical record review services can help clarify the various medical aspects involved in diverse

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lawsuits including medical malpractice, product liability, workers’ compensation, and social security disability.

Medical records may include handwritten or electronic clinical notes, scanned records, emails, text messages, consent forms, oral correspondence between providers, photographs, X-rays, MRI/CAT scans, lab results, printouts from monitoring equipment, video and audio recordings and so on.

Key features of a medical record that could impact medical records review are Relevancy of medical records A major concern is whether the medical records are relevant to the case.  For the medical record analysis to be smooth, the documents should be relevant to the case.  A medical review company can help the attorney understand the benefits of requesting specific medical records.

Accuracy rate Accuracy implies preciseness and reliability of the collected data.

Accuracy rate is affected by key factors such as –    

the dependability of devices and equipment used for diagnoses the reliability of electronic systems used to gather, store, and share information the expertise of healthcare professionals in data collection and documentation access to prior medical records of the patient, and so on

Completeness of the medical record Incomplete charts or missing records could affect the review process.

A complete medical record –     

contains sufficient data to identify the patient supports particular diagnosis validates the treatment and services provided clearly documents the treatment, care, and services facilitates the continuity of care

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Availability or accessibility Disorganized records can slow down the record review process  Accessibility may be affected if the documents are not organized properly Timely documentation Healthcare documentation must be completed in a timely manner.

Delay in documentation could –  affect the care and treatment prescribed for the patient  create more challenges for the reviewer Reliability and legibility of data in the medical record  The reviewer must ensure that the medical details are those of the concerned patient.  Legibility of the handwritten entries is a very important factor.

These medical record features could have an impact on medical chart review, its accuracy, and the ease with which the review is done. A reliable medical record is one that contains accurate information that helps identify the patient; and the documentation should support the diagnoses and validate the treatments provided. The medical record should be accurate, complete, well-organized, clear, legible, timely, and authentic, if it is to facilitate medical records review and make it more efficient.

www.mosmedicalrecordreview.com

1-800-670-2809