How to Find the Jewels in the Pile of Medical Records


Elliot W. Stone, Esq.

 

Nursing Notes

  • Detailed & accurate timeline of events
  • Time when calls made / returned
  • Delayed pt visit

Vital Signs

  • BP, heart rates, respirations temp, etc
  • generally taken by RNs and accurate
  • impact MDs thinking or disconnect
  • if exact same numbers recorded over time prob not checking

Physician Progress Notes & Orders

  • less detailed and often untimed
  • more CYA and may contradict RN notes

Labs & Time Stamps

  • starts clock for response time
  • abnormal labs ignored in making differential dx

Disconnect Between Pt Complaint and RN/MD Documentation

  • ICU
  • hourly physical findings by RNs in flow sheet vs MD physical findings

Code Notes

  • time between entries – more frequent the better

Hospital Policy & Procedures

  • determines whether care giver followed own procedures ie fall risk

Subsequent Treating Doctors & Tertiary Facilities

  • comments re prior care very revealing

Competing Specialties

  • honest depiction of complications or mistakes by specialists cleaning up mistakes

Omissions From The Records

  • gaps in the record
  • MD or patients missing visits
  • long time between actions

MD Not Following Own Advice

  • re ordering a test or medication
  • not following up on test results

EMERGENCY ROOM

  • EMS / Paramedic Records separate from Hospital Record Chart – detailed
  • Triage and Nursing Notes are very detailed (complaints, vital signs etc)
  • in Level I or II Trauma Centers see if Trauma Surgeon saw pt within 30 min
  • premature discharges -vital signs abnormal / systemic issues ie belly chest
  • Policies & Procedures – repeat of vital signs 2-4 hrs (every 12 hrs at minimum)

Outpatient / Office Issues 

  • office notes for thought process and plan to assess problem and fu
  • symptom list form by pt and family – complaint addressed by MD in Dx?
  • disputed phone calls to office – service logs & phone records
  • check Medicare coding (ICD9 Codes) as to what was billed for

RADIOLOGY

  • Time  of scan embedded in the image window  – compare order & when done
  • If the time of reading is delayed – Radiologist probably did not see the study till the reading/sign off time clinician may have done initial interpretation.
  • Tech sheet (MRIs/CTs) separate  – ie amt of contrast (iodine gadolinium). where injected, size of needle
  • RN notes or consent-  whether preps done correctly for CT Scans/GI studies
  • Pt history (prior to contrast injections )  – notes allergies & known medical conditions
  • Portable Chest Films – note distance from pt when taken (6 ft the standard)

SURGERY

  • Indications – compare 1st office visit to date of surgery
  • Pre surg –  ensure renal function, INRs within approved timeframe
  • Informed Consent
  • Timing -relation of operation date and dictation and transcription – inconsistencies
  • delay waiting for path rept (unsure of margins or ill prepared)
  • Residents involvement / where was attending surgeon
  • See if antibiotics stopped timely
  • Compare verbal orders and whether pt was actually seen ie BP issues
  • Anesthesia record-includes intra-op events omitted from op rept ie drops in BP with transfusion, case length, positioning, etc
  • RN notes – can identify issues ie extended tourniquet & operative time
  • Compare OP note & time of procedure
  • Compare OP note with Path Report

POST SURGERY

  • RN Floor Notes
  • PT notes- sudden status changes, compliance issues and variances with MD assessment
  • Causation Issues – primary care records

CATH LAB

  • Catheterizations, angioplasties, defibrillators, EP studies etc
  • Logs not part of records-have to request
  • RN observes and enters vitals, time cath went in & out etc

OBGYN

  • -Fetal Monitor Tracings – Category I II  III (2009)
  • -Category II worrisome changes / III immediate action reqd
  • -Shoulder Dystocia – antenatal risk factors/manuvers * delivery note documentation

OPTHAMOLOGY

  • Cataract procedure – if exceeds 1hr suspect – see time on anesthesia

NURSING HOME

  • Accucheks (blood sugar) -if diabetic/hypoglycemic issues
  • Decubiti – check Protocol to see if followed
  • Falls – check Protocols to see if followed
  • Physician Notes & RN Notes – may be separate

ELECTRONIC MEDICAL RECORDS

  • auto-populated
  • poor documentation
  • can’t tell what asked /changed unless in bold
  • substantiates billing for audits and facilitates report generation
  • Can serve notice to produce data ie templates and drop-down fields

MDS COVERING UP

  • handwriting & pen differences
  • changes in style & flow (short notes vs War and Peace)
  • date/times out of order
  • procedure notes with excuses ie difficult anatomy, uncooperative etc
  • late entries & long notes re discussions with family
  • poor/confusing sign outs
  • information dubious in note or info omitted known at time
  • vague note of getting consultant, GP or RN (to blame)
  • painting a rosy picture when clearly not – compare with RN notes
  • making up highly documented “normal” exam contrary to other documentation
  • Hx and phys exam totally at odds with that provided by plaintiff/family
  • blacking out areas (vs putting line thru and initialing)
  • whiteouts & addendums during relevant dates
  • Residents & Supervising MD documentation discrepancies
  • EMRs tougher to detect / doc can edit -unless check his computer/C Drive for editing

OUTSOURCING OF MEDICAL RECORD SERVICES ABROAD

  • tougher practice climate necessitate better more efficient cost and overhead containment
  • other industries have utilized business process outsourcing to India to lower costs and increase profits for yrs
  • Indian firms with MDs are now targeting US PI lawyers to take over work done by staff & RN consultants

The Present Model for Organizing & Summarizing Medical Files 

  • Performed by Atty/staff (non medical)
  • Non-billable expense to file
  • Independent Nurse Consultants $ 75-$150 per hr – billable expense
  • Paper & binders requiring copying and shipping

The Offshore Alternative

  • Electronic by MDs at $25-$50 ph
  • Medical Opinions – $50-$100
  • Billable expense

The Transmission of Electronic Files

  • Source files are scanned and uploaded and later downloaded thru a secure, HIPAA compliant internet portal.
  • File formats accepted are DOC, XLS, PDF, JPG, TIF, ZIP, and SIT.

The Electronic File

  • Text based medical record summary presented chronologically
  • formatted in PDF or Word
  • PDF version includes navigation tools
  • Hyperlinks- navigation from summaries to corresponding source page
  • Bookmarks-organize file by provider and date

Advantages

  • billable expense
  • frees up staff
  • Reduces file reviewing time and expert bills
  • Eliminates copying & shipping costs
  • Magnified in Mass Tort Claims with large classes

Disadvantages

  • Limited communication (email mostly) with reviewers

Oral communication challenging – Hindi pronunciation and diction