How to Review Medical Records for Medical Malpractice Cases

 

Medical establishments are mandated to maintain accurate medical records for two critical reasons: one is to evaluate the patient profile and analyze results, and the other to set treatment protocols. But of equal importance is the issue of alleged medical negligence; and it is increasing. The legal system depends primarily on documentary evidence to carry out medical malpractice cases. A recorded document stands as primary evidence during a trial to determine whether a healthcare provider is falsely accused or not.

However, reviewing medical records for lawsuits is not easy for attorneys. It is a time-intensive and hectic process and requires an expert to investigate its accuracy. Since attorneys are not medical professionals trained to understand terminologies and validate treatment procedures, they often outsource medical records review.

Some of the challenges that attorneys face include:

• Deal with voluminous and unstructured medical records
• Identify missing and relevant medical records
• Identify complications
• Invest more time and resource than they should
• Lack of expertise in the medical field

Outsourcing medical records review will reduce the investigation burden and help attorneys focus on the case. But it is equally essential for law professionals to look for a reliable partner who follows strict security policies and has a quick turnaround time. Since data breaches have increased, maintaining confidentiality has become crucial. 

For attorneys planning to outsource:

A good medical records review service should comply with all security guidelines, have proper administration, and deliver accurate data on time. The following workflow should be in place:

Step 1:  Medical records retrieval – All authentic and accurate medical records must be retrieved from the healthcare provider with HIPAA authorization from the plaintiff or claimant.

Step 2: Medical records review – A medical professional or legal nurse will conduct unbiased analysis and study on medical records.

Step 3: Summarization – Brief and precise summaries mentioning the specific events and information related to the case will be drafted for easy reference.

Step 4: Special reports – To understand the facts better, supplementary supporting pieces will be provided along with the summaries.

Step 5: Hyperlinking – Easy navigation will be created through hyperlinks and bookmarks to retrieve and refer quickly to incidents whenever required.

Step 6: Medical records audit – A thorough audit will be conducted before the delivery to double-check source records and medical errors.

Step 7: Delivery – Once finalized, the medical data will be shared, complying with all security protocols.

For attorneys planning to develop an in-house team:

Here are fundamental insights for organizations that plan to build an in-house team or hire skilled medical professionals to review records.

1. Understand medical terminologies:

The professional should have in-depth knowledge and expertise to understand medical terms and keywords used in a clinical setting. Also, they should know what relevant details have to be extracted.

2. Learn the components and their relevance:

Since the medical records comprise various documents, it is crucial to understand the kinds of details that will be needed and be quick to identify them. This is why many organizations have nurses or medical physicians to handle the review process.

3. Upgrade or look for skillset:

When you train or hire professionals, make sure they have good clerical competency including typing and active reading skills. This can help speed up the review process.

4. Records indexing:

Indexing plays a vital role in medical records review as it helps to retrieve and access data quickly. In doing so, it helps to identify duplicate pages, missing documents, non-workable pages, etc.

5. Check for actual, fact-oriented events:

Understanding the sequence of events is a must for a reviewer. Only then can a fair and accurate summary highlighting the events be created.

6. Stick with the summary format:

Maintain consistency with the summary format; choose the structure before starting. The most common types include medical chronology, narrative summary, deposition summary, and demand letter.

7. Be clear with abbreviations:

Most common errors arise due to misinterpretation of shorthand. This is one of the challenging tasks for a non-clinical person to understand.

8. Illegible records:

Interpreting poor writing and images could be challenging. Make sure that your professionals have expertise to discern hand-written information accurately.

9. Look for missing records:

Finding missing records will be challenging as it involves many background checks. The reviewer should investigate and write down the date and details to retrieve.

Need experienced advice?

Choosing the right way to review the medical records for your malpractice cases is important. Compare the pros and cons between outsourcing and in-house services before making your decision.

Not sure how best to proceed? Contact our team to discuss or learn more about medical records review.