Litigation Paralegals-The Medical Record Breakdown for Reviewing

When legal claims arise, medical documentation is relied upon to determine the standard of care that was provided. Little or no documentation regarding the course of treatment strongly supports the claim of negligence.
Medical records may expose:
- the series of events that led to a patient's injury and subsequent claim
- inefficient use of information within the medical record
- poor communication from on doctor or department to another
- illegible records or orders
The medical record is one of, if not THE, most important documents within the delivery of healthcare services.It is what tracks the course of a patients care. It allows medical providers to review a patients medical history as well as plan a course of care for the future.
It is a communication tool that not only provides clinical data regarding a patient's current and past medical history, but is also used in the reviewing and reimbursement of insurance claims, lawsuits and to review utilization and quality of care of a patient.
The Contents of a Medical Record Include: 
* Face sheets, encounters for each visit
* Vital Signs
* Physician's orders
* History and Physical forms
* List of Medical Problems
* Medication Lists
* Progress Notes
* Discharge Summary
* Authorization Forms
* Diagnostic Testing
* Laboratory Testing
* Operative Reports
* Pathology Reports
is legal documentation
includes a patient's medical history
chronologically documents a patient's care
allows physicians to plan and evaluate a patient's care
provides continuity in care
allows all physicians involved in a patient's care to communicate with each other
provides evidence of care provided in legal cases
assists in claims review and reimbursement
assists in meeting accreditation requirements

Centers for Medicare and Medicaid Services (CMS) regulations regarding documentation:
Documentation MUST include:
evidence of a physical examination performed no more than seven days prior to admission or within 48
hours of admission
results from patient consultations and the findings from such evaluations
all orders, progress notes, medication records, radiology procedures and results, laboratory results,
and vital signs
the admitting diagnosis
a patient's medical complications
any relevant risk factors
information that reflects the CPT/ICD-9 codes that were submitted to the patient's insurance
consent forms signed by the patient
the discharge summary which summarizes the outcome of the admission, disposition of care, and
plans regarding follow up care
The S.O.A.P. Model
Subjective information includes information given directly by the patient, such as how they are feeling, their opinions on their care, and why they made the appointment. It represents the patient's point of view of their condition.
Objective information represents the physician's point of view. It includes information that was observed and measured by the physician during an examination or test.
The assessment identifies the main diagnosis that is specific to the visit, and includes the physician's interpretation of that condition. When a patient has multiple diagnoses, a physician will dictate their assessment based on the patient's complaint that particular day.
The "Plan" segment is when a physician makes a plan of action for a diagnosis, usually the condition specific to the visit of that day.
The most common challenge within medical documentation is legibility. It is vital that the contents of the medical record are legible to someone other than the author because 1) documentation has a significant impact in resolving legal claims and 2) poor legibility can lead to misunderstandings (i.e. if a pharmacist misreads a prescription and dispenses the wrong drug to a patient).
Any statement made by anyone other than the author of the entry, should NOT be documented as if it were fact. The source of the statement should be noted and the statement itself should be in quotation marks.
A countersignature is a signature from a physician who reviews a record after the primary physician has signed it. The countersignature implies that the physician understands and agrees with the care described by the dictating physician.
It is important to acknowledge, that when a provider signs an entry within a medical record, that they are responsible for whatever is contained in the entry.
Record Retention
The length of time in which medical records must be retained differentiates between statute of limitation regulations and individual state statutes.
However, everyone organization MUST enforce clear policies and procedures regarding maintaining and retaining medical records.
Release of Records
Records may only be release as authorized by individual state and federal laws.
Organizations must also have clear policies regarding the release of medical records that should determine:
* who may request and receive a copy of a patient's medical record
* who is authorized to release medical records and to what parties
* how the practice will protect protected health information
* how releases of records will be monitored and documented
Strong policies on the above greatly assist in avoiding liability.

1 comment:

Sheila Berry said...

Very well written, Jenny. I've worked in personal injury, wrongful death and casualty defense for 30+ years, and I can't see anything important left out of this. I am going to keep copies of this for new paralegals.

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