Why quality assurance is indispensable for medical records

Why Quality Assurance Is Indispensable for Medical Records QA is a very important process with regard to medical records.

Find out why it is vital in the light of medical malpractice litigation.

Medical Record Review

Quality assurance is a very important process with regard to medical records, which are important patient healthcare documents that need to be accurate and totally reliable. When it comes to settling medical malpractice, personal injury, product liability and mass tort cases, these documents serve as very important evidence. Attorneys depend on clear and precise medical case summaries to understand the medical aspects of their cases. Medical records should therefore be easy to review and analyze – something that can be achieved only if they are of good quality.

Good Quality among the Factors Influencing Judicial Decisions A recent study published this April in the Aesthetic Surgery Journal looked at the factors that influence judicial decisions against plastic surgeons. The research was taken up against the background of more lawsuits being filed by patients against their plastic surgeons, often leading to social and financial losses for the physicians involved. The study involved 98 malpractice claims from a state court of justice in Brazil filed between the years 2000 and 2008. 39 closed cases were selected for analysis within the study. It was found that the factors -- quality of the patient medical records, whether written informed consent was obtained, and the conclusions provided by the expert report – were the most influential on judicial decisions.

The cases were associated with breast surgery, abdominoplasty, rhinoplasty and liposuction.

Most complaints were related to scarring and resulting contour; overall dissatisfaction with the results, and post surgical clinical complications. The complaint/complaints made, conclusions from the expert reports, date of decision, presence or absence of informed consent, patients’ medical records and the judicial decision were the aspects the researchers reviewed. 

The study team found that there was a definite association between the presence of a verifiable, written informed consent and a judicial decision favoring the surgeon.

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Well-maintained medical records also proved advantageous for the surgeon, with the judge finding surgeons having good quality medical records not guilty and those with poorly maintained records guilty in all cases.

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It is advisable for the physician to improve the quality of informed consent documentation by having a lawyer review the documents. More importantly, the content should be clearly written so that it is easy to understand.

Ensuring Well-organized and Well-maintained Patient Records As the above mentioned study clearly brings to light, physicians should make sure that they have their patient records well-organized and maintained. This will make any medical review process easy and also serve to create a good impression regarding the physician. Slipshod record keeping will only serve to damage the physician’s reputation and cast aspersions about his dedication and capability. The rule holds the same irrespective of the medical specialty – good medical record keeping is a hallmark feature of dependable and dedicated healthcare providers.

Another important consideration in this context is the way in which medical record review is performed for litigation purposes. If the data mined from the records is to be valid and reliable, the review process should be entrusted to trained and experienced reviewers who follow stateof-the-art QA methods.

www.mosmedicalrecordreview.com

1-800-670-2809