Can you picture an attorney agonizingly studying pages of medical records? What has an attorney to do with medical records? Well, here’s the story…
Medical record review process involves a systematic examination and assessment of patient medical records by healthcare professionals. It includes reviewing various aspects such as diagnoses, treatments, medications, and interventions documented in the records. The process aims to ensure accuracy, completeness, and compliance with healthcare standards.
What are Medical Records?
Medical record is a comprehensive collection of all medical documents pertaining to a particular person. These would include annual health check records, physician visits, hospital visits, admission summary, discharge summary, operative summary, lab reports, etc. The volume of a medical record depends on the number of visits a person makes to a physician, which in turn depends on the presence or absence of chronic medical condition.
Medical Records and Legal Cases
For the year 2018, in the US there were 152,679 Worker’s Compensation claims filed. If you add other medical related cases like Personal Injury or Medical Malpractice, this number will cross 250,000 per year. The key evidence for each of these cases is the medical record of the person involved The key evidence for each of these cases is the medical record of the person involved. Attorneys have to go through every evidence in detail.
As a result, the document discovery agents deliver huge volumes of medical records to attorneys across the US on a daily basis. Once the medical records are delivered, the assigned attorney has to sift through pages and pages of these medical records to clearly understand what transpired to the complainant over a specific period of time and piece together a cohesive case history out of these medical records.
Challenges for Attorneys in Medical Records
Have you ever read a legal document and made any sense out of it? Well, that’s exactly how attorneys will feel when they read medical records. Asking attorneys to read and comprehend medical records is probably nature’s own way of returning the compliment for choosing to write legal documents in their own bizarre way.
Even assuming that a medical record contains neatly typed transcripts, it will still have attorneys scratching their heads trying to understand the difference between “perineum,” “peritoneum” and “peroneum.” If that doesn’t confuse them, then the abbreviations surely will. How are they expected to know what TSH, FSH or GSH means?
The second challenge is that a good percentage of these medical records have handwritten notes scribbled in by the doctors themselves. If you are wondering what the challenge can be, then you’ve never seen a doctor’s prescription before. In fact, I sometimes do wonder if the doctors go through a special training process on how to write illegible notes. The fun part is that attorneys are expected to decipher these handwritten notes.
To add to the misery, the medical records most of the times are not sorted out in chronological order. This makes it even more difficult for attorneys to follow the natural flow of events as they happened and reconstruct the ordeal of the claimant.
The last straw, of course, is the huge volume of these records. Believe it or not, a medical record for an average US adult contains in excess of 1000 pages. In worst cases, these can easily cross 10,000 pages. Thousands of pages of pure horror for the attorneys.
Revolutionizing Legal Efficiency with Expert Medical Records Review
In an ideal scenario crafted by attorneys, they could focus on legal texts while a meticulous process condenses voluminous medical records into a few pages of a palm-sized handbook with neatly sorted chronological data. The medical record review industry aims to turn this vision into reality.
PreludeSys, with over two decades of experience in medical records review services, has been providing this niche service through a dedicated team of trained professionals. Our team studies nearly 100,000 pages of medical records daily, summarizing them into concise, easily readable reviews organized chronologically. The outcome is a handbook reduced to 1/100th the size of the original records, containing all essential data needed by attorneys.
Transform your tedious medical records review process effortless by meeting our experts.
FAQ
1.How long does the medical record review process take?
The duration of the medical record review process can vary depending on the complexity of the case, the volume of records, and the specific objectives of the review. It may take a few days to several weeks to complete.
2. What are the key objectives of the medical record review process?
The primary objectives of medical record review include ensuring patient safety, identifying medical errors, assessing the appropriateness of treatments, verifying billing and coding accuracy, supporting insurance claims, and providing evidence in legal cases.
