What are the 4 most common medical record analysis barriers you will encounter as a legal nurse consultant?
Disorganized medical records
The records come into your possession in no particular order. They were scanned and saved to a disk before they were organized, which requires you to sift through them to rearrange pages. You may receive multiple copies of the same record. Or the paper copies are disorganized, requiring you to separate them into sections and rearrange the order.
Worse yet, the person who copied them used the double-sided feature, but did not copy them in sections. You encounter a page of physician’s orders on the back of a lab record, for example.
It is inefficient and counterproductive to start medical record analysis with jumbled records. In order to make sense of the records, you will most likely need to impose some kind of system on the disorganized records: rearranging them, reshuffling them, relabeling them, and possibly even recopying pages.
The attorney’s office asked for an abstract (a subsection of the medical record) instead of the full certified copy. In many situations, in order to evaluate the case, most likely you will need a full certified copy. This is particularly true when you are screening a medical record for a possible medical malpractice claim, evaluating a case as an expert witness, or summarizing the complex care a patient needed.
Another reason for missing records is failure to copy or provide all of the relevant sections of the medical record, even when a full certified copy is requested.
Remember, for most attorneys, the medical record is just a stack of paper or an electronic file. The attorney relies on your knowledge of what should be in the record to recognize what is missing. Be clear and detailed about what is missing. I find attorneys prefer to receive the list in writing so they can work with the provider to get the missing documentation.
Illegible handwriting complicates medical record analysis
The medical record is typically, at this point in time, a combination of handwritten and computer generated records. The handwriting and signatures may be indecipherable to everyone, including the person who created the records.
It may be necessary to get a transcription from the person who created the record. Some states have statutes that require providers to give a transcription at no charge. Your knowledge of medical terminology should help you decipher some of the difficult to read handwriting. If you can’t determine whose signature you are looking at, in most states the provider is obligated to provide names of employees who charted in the medical record.
There are entries that do not make sense, are inconsistent with other information in the chart, or may have been added after the fact or changed.
Using the detail-oriented part of your skill set, you may find it helpful to construct a chronology or timeline to identify the discrepancies. Inform your attorney client about the issue so he or she may consider the legal implications of a possible altered medical record.
Medical record analysis can be challenging enough without the barriers I have described in this post. Communicate with the attorney when you run into these issues so you can get the best records for your analysis.
Pat Iyer MSN RN LNCC is a coeditor of Medical Legal Aspects of Medical Records. This is an essential reference for your LNC library.