When a case relies on medical evidence, legal professionals need well-organized, comprehensive medical records. They also need a thorough understanding of every item in those records and the treatment, care and patient experience they reflect. For paralegals and attorneys, Legal Nurse Consultants can quickly cut through the complexity of dense medical history and pinpoint vital evidence.
This blog post continues a series on medical record organization, and focuses on printing and organizing electronic records, surprisingly complex tasks. The next and final installment in this series will spotlight digital medical charts.
GOING BACK TO PAPER
Attorneys are often overwhelmed by the volume of material they receive when a medical provider forwards electronic medical records. Even though electronic record system are intended to produce less paper, they actually contain more documents than a typical paper chart. With an almost endless capacity for storage, electronic patient record systems encourage excessive documentation. Think digital cameras: We shot way fewer frames when we paid to develop film. When today's electronic records are printed, they’re often many times larger than the average hard copy charts.
Although we're firmly in the digital age, many healthcare facilities in the United States are still transitioning to electronic medical records. Some still actively use handwritten records. Others keep archived paper records in binders, while electronically storing more current records. Still others have scanned all past records into the existing digital chart. Because of this inconsistency in formatting, any medical records request should stipulate that you want all paper copies of the medical record, including handwritten notes, as well as any electronic portion of the medical record. It may not be obvious whether the facility supplied all of the records unless you have an opportunity to view the original electronic medical record on site, so consider this option.
Occasionally certain peculiarities show up when printing electronic records; these may either help or hinder the organization process. Electronic medical records can be trickier to organize than handwritten medical records. While most paper charts are organized by type of record, a software program may print records in chronological or even random order. For example, the nurses’ notes may not be printed in sequential order.
On the other hand, some systems print an entire record in chronological order, regardless of the department. This means that a 48-hour period may include a radiology report, an operative report, a recovery room report, and then a progress note. Dividing purely chronological records into typical sections then becomes a nearly insurmountable task.
Even when electronic medical records are printed in sections, they’re often continuous, without page breaks to separate reports. For example, the top half of a page may contain the most recent physician order, while the bottom half contains a radiology result. It may be necessary to photocopy that page and place each copy with the applicable section of the chart, a tedious but necessary detail.
Certain software aggregates all of the notes which relate to a specific aspect of the patient’s care. All cardiology, orthopedic or skin integrity assessments, for example, may be printed out one section after another. Leverage this chunking of material by creating subsections in your printed medical record.
NURSES ARE NECESSARY
Another complicating factor: Nursing notes from computerized medical records tend to be extensive, numbering into thousands of pages. Though very little changes between nursing shifts, each new nurse is required to enter notes for that block of time. Adding to the redundancy, sometimes the software is set up so the same information prints multiple times. Nevertheless, nursing notes are a vital component to a complete medical record, and should be specifically requested.
Once an electronic record is printed, organizational challenges can make critical analysis difficult. If a legal professional wants to determine patient status at a particular point in time, it’s cumbersome to wade through multiple sections, attempting to piece together an accurate picture. A Legal Nurse Consultant can cut through any superfluous data and mine the record for vital information, freeing the attorney to focus on what's most important: serving the client.