Medical Record Review

The attestation is the last document included in the file after the discharge summary. It should contain a summary of the patient’s diagnoses without using medical abbreviations and the treating physician’s signature.

Before you can review and analyze necessary patient medical records, the first step is medical records retrieval . Similar to the review process, medical records retrieval can be an arduous and time-consuming task due to rigorous HIPAA standards and the number of providers and records within a medical file. Once obtained, there are various steps to review these records accurately and effectively, including:

1. Organizing and indexing the records: Medical files are often highly disorganized. Organizing them makes locating information quicker and easier and can help you identify what may be missing.
2. Creating a case chronology: Creating a clear timeline of medical treatment can help determine causation and enables you to avoid mistakes when supporting relevant claims.
3. Analyzing the records: Reviewing the data based on your clients’ claims is critical for determining which information is relevant to your case. Quality assurance is also crucial.
4. Identifying and retaining qualified experts: Medical records review can help determine if you need expert witness testimony and precisely which information needs further explanation or verification by expert opinion.

An admission record is usually the first page of a medical record. It contains the patient’s personal and financial data, including the patient’s name, address, age, date of birth, sex, race, marital status, religious affiliation, and nearest relative or emergency contact. It should also contain a short description of the patient’s condition upon admission, suspected diagnoses, and the name of the attending physician who is treating the patient.

You can also find the history and physical report near the front of the compilation of the records, if present. It contains the doctor’s initial observations, the patient’s past medical history, and family medical history. It should be typed and signed by the doctor.

Doctors’ progress notes are usually handwritten, making them difficult to decipher. They also tend to be less comprehensive than nurses’ notes. Still, they are often most helpful in understanding the chronology of treatment and usually include the doctors’ reasons for treatment decisions and patient care.

Since additional or specialty consultations are not always necessary, the patient’s medical records may not always contain a consultation report. If present, the report includes evaluations and recommendations from the consultant.

Physicians’ orders detail the medications and treatments prescribed to the patient and any necessary instructions. Physicians do not always keep these records daily. The forms are usually in triplicate—the white copy stays in the medical file; the pink carbon copy goes to the laboratory; and the yellow carbon copy goes to the pharmacy. Once the relevant parties fill the orders, the medical offices destroy the corresponding pink and yellow copies.

Physicians’ orders may be relayed to and signed by a nurse on behalf of the treating physicians, or the orders may be handwritten by the doctor. It’s also possible that the orders may be in a non-triplicate typewritten form if the hospitalization was for a routine procedure.

Laboratory reports include patient results for bloodwork, pathology, blood typing, and other clinical tests. These reports are usually on separate, smaller forms.

Diagnostic reports include radiology and X-rays, CT scans, ultrasounds, EKGs, EEGs, and cardiac output data. Medical practitioners usually sign these documents with a stamp rather than a signature. X-ray films and CT scans are not routinely provided with the patients’ medical records and must be requested separately.

Healthcare providers generally divide anesthesia records into pre-anesthesia, anesthesia, and post-anesthesia forms. The pre-anesthesia record may also be found in the operative report and describes the patient’s previous medication history and the choice of anesthesia due to the planned procedure. The anesthesia record details the type of drugs administered to the patient, when given (i.e., date and time), and notes on the patient’s condition during surgery, including any complications from the anesthesia. Lastly, the post-anesthesia record includes an evaluation once the patient is in recovery.

Someone typically prepares operative reports per dictation, so it’s possible they contain inconsistencies or might be missing data, making it essential to check these notes carefully. The operative reports describe the technical aspects of surgical procedures, the surgeon’s name, the bodily tissues affected by the operation, the condition of the patient after surgery, and additional post-operative diagnoses.

Nursing notes provide daily summaries of patients’ conditions, needs, limitations, appetites, complaints, and appearances. These notes are most often the best source of information and may include graphic charts, I/O reports, and medication reports.

• Graphic charts: These charts contain measurements of patients’ vitals, including temperature, pulse, respiration rate, and blood pressure.
• Intake and Output (I/O) Report: This report is critical if the patient receives IV fluids or if kidney function is at issue. Medical providers record the information at the end of each shift.
• Medication Administration Record: This record includes details about medications administered to the patient, including types, dosages, and when (i.e., date and time) given. If the patient stays in the ICU, this information will be on a separate form.

This report includes instructions provided to patients by nurses regarding treatment plans, diet and activity restrictions during recovery, medications prescribed, and any symptoms to report. The on-duty or treating nurse and the patient sign this document upon discharge.

Discharge summaries provide an overview of a patient’s visit and hospital stay. The document includes physicians’ findings, a summary of diagnoses, medications prescribed, and instructions given to the patient upon discharge. A discharge summary is often in typewritten form, dictated by the primary care physician, including a transcription date and the doctor’s signature.