Voluminous medical records are a major challenge for personal injury lawyers which require medical record review to understand the medical issues in the case. The attorney needs to spend considerable time for the medical record analysis so that the nature and extent of damages can be determined. The records to be reviewed include physician visits, annual health check reports, hospital visits, admission and discharge summaries, operative notes, lab reports and so on. The more the number of visits the patient makes to a doctor, the more the medical record volume.
The medical record of an average American adult can contain more than 1000 pages. This could easily cross 10,000 pages. Speaking from an insurance point of view, all copies of medical bills and records related to the accident and injury have to be submitted to the insurance company for review and determination of damage.
Though it is challenging to obtain all the records from various custodians, efforts have to be made to ensure that a complete set is provided to the insurer. This will help prevent claim denial and ensure full compensation.
Challenges Involved in Chart Review
- Handwritten notes and illegible handwriting: Legal professionals often have a tough time with these issues in the medical records. They may not be able to understand what actually occurred with the patient’s care. It may not be possible even to find out who wrote what, when the names are illegibly written.
- Abbreviations and jargon that are difficult to understand: Often the abbreviations and jargon the doctors use become difficult for attorneys to comprehend – for instance,
- C/O for “complaining of”
- The number 2 that is often used and stands for “secondary to”
- QID for “four times a day,” TID for “three times a day” and BID for “two times a day”
- PO means that the medicines are to be administered orally
- PRN means that the medication, including that for pain is to be taken as often as needed for pain control
- A small triangle means “change”
- A small “s” with a line over it stands for “without,” and a small “c” with a line over it means “with”
These usages can be easily understood by a professional medical review company, which makes their service helpful for attorneys looking to save valuable time and effort.
- Charting systems are not uniform: Since the medical records are from different facilities, the charting systems may be different. This makes medical record organization and review very difficult.
- Incomplete medical record set: Even when copies of medical records are sent as a complete certified copy, the report may be missing out on nursing notes, surgery reports and so on.
- Meaningful information may not be available on the EHRs: EHRs are legible but they may not contain meaningful information. The software is sometimes awkwardly designed with a number of screens the healthcare provider must click through just to add data to checklists. There is a possibility of loss of narrative data, which is most important to understand personal injury cases.
- Lack of chronological order: Typically, the medical records are not properly arranged or sorted out. Attorneys find it difficult to follow the sequence of events and reconstruct the claimants’ ordeal.
No doubt, medical record review for personal injury attorneys is highly challenging but the entire process can be made easier with medical review services from a good provider. This will ensure that attorneys have all the medical facts clearly presented to them so that they can quickly evaluate damages and maximize their time, judgments, and settlements.
The important thing about hiring an external agency for the record review is that they have expertise in reviewing thousand of medical records for litigation requirements. You can rest assured that the records will all be analyzed for abnormalities and inconsistent documentation, if any. Moreover, the medical review team would provide brief, easily readable, chronologically arranged records.
View our infographic “Common Challenges In Creating A Good Medical Record Review For Legal Trials”
