Medical Record Review and Analysis

by | Last updated Jun 12, 2023 | Published on Oct 1, 2010 | Medical Outsourcing

Medical Record Review
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Medical records serve as a clinical, administrative and legal document, containing all the information about a patient’s diagnosis, treatment provided, and the final outcome. Medical record review and analysis involves evaluating a patient’s healthcare information for medical or legal purposes. Hospitals, insurance companies, attorneys, and law firms require review of medical records for diverse purposes. While attorneys and paralegals use medical record review to prepare for litigation, hospitals use it to manage patient records, easily identify any missing records, and ensure appropriate patient care. Insurers need proper review of relevant medical documentation to evaluate the claimant’s eligibility for compensation. Attorneys mainly require a medical chart review to collect all key points related to the injured person’s health condition and to determine the nature and extent of damages. Law firms dealing with personal injury, medical malpractice, mass tort or workers’ compensation cases have to refer to voluminous medical records to understand the medical issues in the case. These reviews assist attorneys to easily identify the strong and weak points in the cases they handle.

The medical records that are reviewed mainly include: Notes from treating physicians, Nurses’ records, Anesthesia reports, Reports from radiologists, Prescription orders, Lab reports, Consent forms, Correspondence between healthcare providers, Patient consent forms, Authorization requests, Accident reports, etc.

The medical record review and analysis team usually includes licensed healthcare professionals and board-certified physicians. They carefully review the patient’s past medical records and medical history, and prepare medical record review chronologies and summaries. Often, experienced reviewers are assigned to review medical charts to ensure whether they are complete or accurate, or to extract some facts out of those records.

What Does Medical Review Services Involve?

Professional medical review companies provide medical records services such as – medical records organization, case chronology support, plaintiff fact sheet preparation, deposition summaries, case history and summary, medical chart review, and trial preparation.

The medical review process involves key steps such as –

  • Retrieving medical records from relevant sources
  • Organizing the records in a chronological way to provide a clear idea regarding the patient’s medical journey
  • Developing medical record chronology for an accurate timeline of all medical encounters (Case chronology can be prepared using methods such as abstraction, episodic, or collaborative)
  • Transcribing and interpreting any records that are in the form of dictated notes or interviews
  • Creating medical case summaries (in PDF or word format) that provide the medical facts based on the nature of injury, ER treatment, details of hospital stay etc
  • Hyperlinking and bookmarking to navigate between the summary and the source records quickly and effortlessly
  • Reviewing and comparing reports
  • Identifying any missing records and treatment inconsistencies
  • Removing all duplicate medical records and maintaining a log of the deleted files
  • Conducting a multilevel quality audit process to prevent any errors in review

All the details in medical records are classified by data type, referencing the type of service, provider of service, place of service, and date of service. Proper review also helps to extract information such as patient demographics, medical care provided, diagnostic procedures including lab tests, imaging studies and so on.

Performing the review process in-house may be difficult, because legal personnel may not have a medical background. They will find it challenging to handle the voluminous, unorganized medical data, properly manage the medical documents, comprehend manual notes, medical jargon and abbreviations, identify missing or misplaced records, and meet HIPAA compliance requirements.

At professional medical billing and coding firms, the review services are provided by trained and experienced professional medical record review teams comprising registered nurses, therapists, other healthcare professionals and documentation specialists. While outsourcing, make sure that the team is skilled and knowledgeable in handling large-volume medical records.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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