Guide to medical chart review and its many challenges

By Juliet D'cruz

Clinical record review or medical chart review is a process designed to obtain retrospective data to answer key clinical queries. Such a service is usually required to answer specific clinical questions, but in a less resource-intensive manner. However, it would be a mistake to consider such information limited or inadequate.

Why do lawyers need medical record review?

The job of a lawyer is challenging and needs in-depth case research, especially when he or she is preparing for a trial. However, the process becomes far more complicated when they are forced to go through medical records. This is where medical record reviewers or a medical chart review nurse comes into the picture.

To begin with, the process of medical chart review involves studying the case notes or the structured database that has already been recorded, and summarizing it properly for drawing inferences. In the case of clinical records, it bears data pertaining to one’s tests and treatments. In fact, it summarizes their entire medical history, enabling lawyers to understand the case properly.

So, in short, medical chart review allows the lawyer to evaluate the patient’s healthcare information. He reviews, interprets, and even analyses the data, provided by a medical chart review nurse or a similar service provider. That said, such records aren’t just helpful to lawyers, it is also of a great help to legal nurse consultants, insurance staff, as well as medico-legal case review firms.

The process behind medical record review

  • It starts with collecting and arranging the various medical records of the patient.
  • The next step is to look for any and all misplaced/ missing medical records.
  • The process even involves discussions with healthcare providers (if any).
  • It involves recognising aspects that may have a bearing on an individual’s alleged injuries and damages.
  • The next step is summarizing the important aspects of the data and putting it nicely in a written report.
  • It also involves making a chronology of events.

Thus, medical chart review and summary has a notable bearing for lawyers involved in cases pertaining to product liability or personal injury. The summary helps them form a deeper understanding of the case and prepare for the trial.

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Challenges of medical record review

As you might have figured it out already, medical records are often voluminous and intricate. The law firm thus either needs a medical chart review nurse to help them with the medical aspects of the case, or hire someone who can come up with a professional and reliable medical chart summary. Some of the challenges faced by lawyers include the following.

  • Stacks of medical records: The medical records that reach the lawyer or the law firm ahead of the trial are raw and unorganized. In fact, the records are sourced from multiple hospitals, diagnostic centres, and healthcare providers, thus they lack structure and order. In fact, these may also include irrelevant records. Thus, a medical chart reviewer sifts through the records to make sense.
  • Lack of narrative data: It is true that healthcare providers are actively switching to the new-age system of electronic medical records, particularly for data backup and convenience. However, such files lack narrative data or even doctor observations.
  • Medical jargon: There are times when we come across medical practitioners who still follow the old-school method 0f handwritten health records. Thus, it’s often hard to track down or understand the details of the injury and treatment. Most law firms, thus have a dedicated medical chart reviewer to help the team decipher similar medical records.

Key takeaway

A medical chart review is a great tool – whether it be for collecting data about a particular surgical or medical problem, or an investigative procedure. People use record reviews for seeking answers, and that’s why, only professional medical chart reviewers such as a medical chart review nurse are brought in for the effective utilization of record reviews. Their experience and expertise allow them to review the data better and provide information that’s relevant.

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