Over the last several months I've detailed the complexity of organizing and analyzing medical records. Clearly, it takes a great deal of time to do this task justice. If just anyone could read medical records, you wouldn't need someone with medical background to assist in correct interpretation and preparation (the keys to any successful case)
Electronic medical records (EMRs) produce new—and sometimes confusing and voluminous—documentation. Understanding the implications of the transition from paper to electronic record, both generally and specifically, helps you make sense of all of this information.
Think of the accuracy of medical records as a continuum: At one end are accurate records; at the other end are modified records. Patient data becomes suspicious when there are detailed supplements, including information that might even be accurate and valid. Watch for detailed notes about treatment, patient discussion and post-treatment counsel. This is particularly important when there has been a negative outcome.
Risk managers call these addenda “panic notes;” they're almost always written because the healthcare provider has realized that the patient experienced a serious complication; the provider may even have discovered that the patient has consulted an attorney.
Tips for organizing digital records, including recommended hardware and software to streamline a complex task.
Attorneys are often overwhelmed by the volume of material they receive when a medical provider forwards electronic medical records. Even though electronic record systems are intended to produce less paper, they actually contain more documents than a typical paper chart.