Medical records are at the heart of handling cases with medical issues. Just about every medical case you can think of involves medical records. Your ability to understand what is in the records and how it impacts your cases is one of the skills you need as an attorney.
Organizing medical records is a skill that improves with time. Legal Nurse Consultants have a tremendous advantage over paralegals and attorneys in their ability to organize medical records. They understand how the healthcare system functions and can more readily read documentation, even if they have never seen records from a specific facility before.
This blog post provides tips for making handling medical records easier and more efficient. In future posts, I will cover how to organize paper, electronic and scanned copies of medical records.
Organizing medical records is time-consuming and can direct an attorney’s focus away from other aspects of his/her law practice, so many delegate the task to a legal assistant or Legal Nurse Consultant (LNC). Others want to organize their own records; they prefer a hands-on approach and feel they understand the case better when they personally review each document.
The amount of time required to organize medical records depends on whether the records are typed or handwritten, clear, provided in sections (or completely scrambled), how the are supplied, and the program used to create them.
Your law firm might receive paper records or computer files containing records. Those records might have been scanned or generated by an electronic medical record system. It's always helpful if scanned records have already been organized; it is a bigger challenge if they were scanned in no particular order.
An attorney sometimes develops an idea of how long it will take to organize records — which might be realistic, or not. If you ask a Legal Nurse Consultant to handle the task (which I recommend) be sure to communicate your time estimate. Expect the LNC to keep you informed if the amount of time to organize the records will be longer than expected.
PRINCIPLES OF ORGANIZING MEDICAL RECORDS
The patient’s providers may have handwritten records, or combined handwritten records with electronic medical records. This combination is a hybrid of records. At other times, the records may be completely in electronic format.
One of the biggest tips in organizing medical records is to use a consistent format. It is easier to locate information when you develop a system, placing the same sections of the medical record in the same order every time. A consistent format helps you and your colleagues and provides consistency for paralegals, legal secretaries and experts involved in the case.
- Use purchase pre-printed index tabs. Do some online searching for the best prices; hospital and nursing home index tabs marketed to attorneys tend to be more expensive than those sold to hospitals. You will find it useful to have two sets; one set specific to hospital records and one specific to nursing home records. Index tabs save a great deal of time when organizing records because it’s easy to slip a divider in between the sections.
- Organize paper records in an uncluttered environment where you can spread out, such as on a table. Have only one person’s medical records on your work surface at a time. Otherwise you are at risk of mixing up information and putting the wrong information in the wrong chart.
- It is helpful to place a cover sheet on top of a group of records. Your cover sheet should state the name of the facility or provider and the first and last days of treatment. This will be helpful when you place the records in chronological order.
Abstracts vs. Certified Records
Whether you need abstracts or a full certified copy of a medical record depends on the type of record and case. Abstracts might be sufficient in cases other than medical malpractice. The problem is, there is no standard definition of an abstract. A medical records supervisor might decide what he/she thinks you will need. However, what you think you need and what the medical records department thinks you need could be entirely different.
When a personal injury attorney is accustomed to getting abstracts, he/she might not understand that LNCs and experts for medical malpractice cases need the full certified chart. Certified means that someone in the medical records department has reviewed both the original record and the photocopied/scanned record to verify that every page has been duplicated. Lest you rely on that being accurate, keep in mind that someone is supposed to go through and check all those details. It is possible the individual does not notice the back of a page has not been copied, for example, and yet will certify that it is a full chart.
Always take those certifications with a little grain of salt and make sure that you look to see if there’s anything missing. For example, sometimes a three-page consult or an operative report might be missing one of the pages. In a medical malpractice case, a single missing document could have a profound impact on the case. It’s imperative for the attorney and/or the LNC to insist on receiving complete medical records. Below are examples of two cases in which medical records were missing or incomplete. Bottom line: don’t take "no" for an answer when what you want is important!
- Case #1 involved a patient whose neurovascular status was acutely changing; the patient was developing compartment syndrome. During this time, the nursing staff was ordered to perform a neurovascular assessment and to document on a neurovascular flow sheet. On the morning when the patient was diagnosed with compartment syndrome, the surgeon evaluated the patient, reviewed the medical record, and noted there were very sparse entries on the neurovascular flow sheet. This was the one document that was missing when the attorneys obtained copies of the medical record. This case went into suit. During a deposition, years after the patient received care, one of the nurses testified the last time she’d seen this missing document was one year earlier in the risk manager’s office. Thankfully, the orthopedic surgeon recalled seeing this medical record and noted there was little documented on it. The jury awarded a large verdict.
- Case #2: All of the medication administration records and the nurse’s notes were missing. The facility asserted they had given the plaintiff attorney everything. The defense attorney got irate: “We gave you everything”. The expert told her client, “No, they didn’t. That patient couldn’t have been in the hospital for two weeks and there not be any medication administered, especially given why the patient was there.” The attorney kept asking for the records, and the facility kept denying they had more. Finally the attorney went to the hospital medical records department, where he found 600 more pages of medical records for a chart the facility had asserted was complete.
Duplicate medical records are a challenge which can consume a lot of time during the organization process. A duplicate record is identical in all ways to the original and is found within the same set of records. It is NOT a duplicate, however, if you find even one word which is different or something else which has been changed on that record. If you find records from Dr. King in Dr. Queen’s records, these are not duplicate records.
Figure 1.1 shows a one-foot high box of duplicate records that were removed from a set of medical records. This is a huge waste of resources in many ways. There’s no point in sending a LNC five copies of the same page, but often attorneys do not have the resources to organize records before sending them.
If you find duplicate pages with different dates, this could be because the parameters in an electronic medical record system direct the program to print out several copies. Each new piece of information triggers a new version of the record.
NEXT TIME IN THE BLOG: ORGANIZING PAPER RECORDS
THE VALUE OF A LEGAL NURSE CONSULTANT
As a Legal Nurse Consultant, I have the knowledge and experience to gather the relevant records, analyze the information, and determine what is missing. I handle the research so you can focus on the client and other matters related to the case.