medical record review

When it comes to managing compensation claims, the review of medical records is an important activity. It is also one of the most tedious jobs that involve combing through hundreds of pages of records relevant to the claim. The medical review professional assigned to this task must have complete focus and almost maniacal attention to detail. It can be compared to solving a jigsaw puzzle or a Rubik’s cube; the challenges involved are similar. 

This blog details the processes and challenges involved in medical records review.

Retrieval of Records

Electronic Medical Records (EMR) represent the comprehensive set of medical history that has been collected on an individual since their birth. These records are retrieved from the hospitals and thoroughly checked for accuracy and for any missing links before a review process begins.

Sorting of Records

The medical records contain hundreds of documents. These documents are sorted by category to isolate non-claim related documents to speed up review. The DNP (date, page number, and provider) exercise follows this process and designates the documents that will be used for case-specific review.

Challenges in Medical Record Reviews

Understanding Medical Terminologies

For an accurate interpretation of medical records, the reviewer should have an in-depth knowledge of medical conditions, causes, complications, standards of care, treatment options, and their impact. For example, a nosebleed is a common word we use in our day-to-day lives. However, epistaxis is used for the same condition in medical documents. The reviewer should be able to simplify complex medical terms into something simple in order for non-medical people, such as attorneys, to understand and proceed with the case.

Speed-Reading 

Medical records are voluminous. The reviewer should have speed-reading skills to sift through the pages quickly and have a well-developed strategy to manage time efficiently, especially with long notes such as AME and QME reports.  

Handwritten Notes and Medical Short-Hands

Have you ever tried to decode a physician’s handwritten prescription? If so, then you understand the demands and the challenge of accurate interpretation. You should analyze the handwriting pattern and apply this to similar areas of the document. The reviewer should not misinterpret this by mere assumption. 

We should never underestimate the creativity of healthcare professionals when pressed for time. But unfortunately, even standard shorthand used in the clinical setting become scrambled and the documentation can reflect something entirely different from the original intent. 

With poor handwritten notes, you should summarize only the verified and confirmed data to validate the information available in the patient’s other medical documents. However, an expert reviewer can normally crack these illegible notes.

Distorted Documents

Documents from previous years are still in paper format and are sometimes illegible. In addition, they do not stand up well to scanning because of the wear and tear over the years. In some cases, the reviewer needs to reproduce the actual medical language from the documents to avoid confusion. An Optical Character Recognition (OCR) software copies non-editable documents and converts them into editable and searchable pages. Unfortunately, with these distorted documents the tool does not often work. The reviewer has to focus hard and manually type out the content in these cases.

Abbreviations

Medical abbreviations are tricky. The same abbreviation can be interpreted differently for particular medical specialties. For example, the acronym MS means mitral stenosis for cardiology. However, the same MS means multiple sclerosis for neurology.

Data Security

Medical records consist of sensitive patient information, including demographic data. Therefore, HIPAA guidelines mandate these to be protected all the time. In addition, the data should have end-to-end encryption and secret keys for additional security. 

In-House Medical Record Reviews

There are several complexities in medico-legal cases, such as misinterpretation of medical terminologies and the deadlines attached to the review process. A non-medical person without the necessary expertise assigned to medical record review will encounter all the above challenges. The final summary may not properly reflect the claimant’s damages.  

PreludeSys – A Simple Solution to a Complex Problem

PreludeSys is an ISO 27001:2013 certified company and has more than two decades of experience in delivering medical record summaries for law firms, Workers Comp attorneys, and insurance companies. Outsource your medical record review process to PreludeSys for better results. We have:

  • Specialized Teams: Expert review personnel are skilled in medical terminologies.
  • Superior Technology: We use specialized software for our medical record indexing to provide clients with hyperlinks for easy access to critical points of the medical data.
  • Data Security: We adhere to HIPAA guidelines and provide data encryption.
  • Competitive pricing: We value our relationships with clients and deliver the best value for your medical review needs.

Talk to our experts today for a comprehensive and accurate medical record review solution.

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