Medical cases hinge on well-organized, accessibly medical records. In addition, legal professionals need a thorough and accurate understanding of the medical care and procedures those records represent. Legal Nurse Consultants can save time and expense for paralegals and attorneys by efficiently deciphering the complexities of medical records and finding the evidence to support a win in court.
This blog post continues a series on medical record organization, and focuses on making the most of digital charts. The next installment will wrap this series and spotlight how to obtain the best possible medical records.
In the past, it was common to manage medical record in paper files. Increasingly, attorneys and legal nurse consultants are opting to utilize computerized records. Consider the costs of paper records: copiers, paper, toner, postage, indexes, binders, storage. Electronic records are easier to store and extremely portable. In addition, e-files (such as PDF) are searchable; the ease of locating specific information among hundreds of pages saves time and frustration.
While a variety of options exist for online digital file transfer, some facilities send medical records via CD. Many medical providers have transitioned to electronic charting, but have a combination of paper and scanned archives. If you choose to manage medical records digitally, you’ll most likely need to scan some paper records.
It’s increasingly common for medical providers to supply medical records in PDF form. HIPAA laws protect these electronic files, so attorneys need to exercise care when they transmit them to their LNCs and experts. Encryption and/or password-protected accounts provide an extra layer of confidentiality.
Regardless of delivery method, start by ensuring that all records are in a readable format. Then take time to review and organize each complete record before searching for specific evidence.
EASY ON THE EYES
As with any task, it’s important to have the right tools for the job. Organizing and scrutinizing electronic charts is significantly easier with multiple monitors. As you gather evidence, you’ll want to manage the records on one screen while making notes on another. With multiple displays, you increase your workspace and eliminate the need to toggle between windows. This increases speed and efficiency, helping you accomplish a once-enormous task in a fraction of the time.
THE RIGHT HARDWARE
The following tips will help you create an appropriate workstation for reviewing medical records.
- Consult with an IT expert to build a dedicated work station, including a computer with appropriate graphics card. It can be difficult and expensive to retrofit an older computer with the right graphics card.
- Consider purchasing all your monitors within the same brand so that images appear the same when transferring/dragging to extended displays.
- Buy the largest affordable monitor that fits your workspace.
- Widescreen monitors are better for viewing in portrait mode.
- Invest in high-definition monitors. Medical images and records need to be viewed in detail.
- Mount monitors on a rotating base, so you can switch to portrait mode when needed. Viewing a record in landscape format may require enlarging the content and then scrolling to read the entire page. A portrait display is long enough to capture an entire page at one time.
- Wall mounting is an ideal solution, as it frees desk space.
- A three-monitor station allows you to simultaneously utilize a database, PDF document and Word file (for example).
THE RIGHT SOFTWARE
Because many records will be in PDF format, you will likely rely on two Adobe software programs: Adobe Acrobat Reader and Adobe Acrobat. Adobe Acrobat Reader is free to download, and it allows you to open, print and save PDF files. Adobe Acrobat must be purchased; it enables you to manipulate the files. Acrobat is a valuable tool. With it you can:
- add flags, comments and watermarks
- insert, delete and reorder pages
- insert images
- add watermarks
- break pages from the medical record into separate files (i.e. nursing notes, physicians’ orders, lab tests)
- combine PDF files
- insert a section of the medical record, such as an x-ray report, into your Word file
Adobe Acrobat has some particularly helpful go-to capabilities:
Bookmarking: Bookmarking allows you to select and highlight text and then save that location as a bookmark; you can label these as needed. Each bookmark will populate in a left-hand index, allowing you to track your bookmarks. This dropdown menu gives you quick access to records of interest.
Indexing: Indexing asks the software to examine the document, identify natural breaks and create sections accordingly. This function helps you quickly organize large files.
Convert and Export: When researching, you may find it useful to add documentation to the case file alongside pertinent medical records. Acrobat allows you to convert web-based pages to PDF files, and then add them to the existing record. Conversely, existing PDF files can be extracted and exported in other formats, such as Word.
Find: Acrobat uses optical character recognition (OCR), allowing you to utilize the “Find” command to locate content. While OCR is not perfect; this capability will significantly enhance efficiency.
Text Notes: Text Notes allows you to create comments in the medical record. Rather than having to record notes on a separate document, additional users can read your note and respond within the PDF.
PAGE NUMBERING COUNTS
Medical records can be a messy amalgamation, and there is no true order when they’re first received. Once you’ve organized the document according to your purpose and preference, you’ll need to assign page numbers. Organizing and numbering pages is a service some Legal Nurse Consultants offer. It’s important that numbering is put in place before a team handles the record; this guarantees consistency and clear communication among team members. It’s worth noting that Acrobat has Bates Stamping as an option when creating your page numbering system.
GO SLOW TO GO FAST
Electronic medical records take time to organize into useful files, but once the arduous, upfront work is complete, these electronic files are user-friendly and efficient. Legal Nurse Consultants lend an expert perspective when sorting technical medical records; putting their experience to work can save legal professionals valuable time.