Medical record is the precise documentation of patient’s medical history, hospital course, clinical management and treatment rendered. Medical records can be categorized as outpatient records and inpatient records. The outpatient records include emergency room visit note, office visits, therapy visit notes and follow-up visits. The inpatient records include history and physical, progress notes, consultations, preoperative note, operative note, postoperative note, therapy records, physician orders, nurse notes, medication administration record and discharge summary.
Uses of medical records
- Track patient’s progress and treatment provided
- Assures continuity of care
- Insurance reimbursement purposes
- Database and registries
- Legal evidence for medical malpractice
- Substantiates damages in personal injury claims
Medical records are considered as potential legal documents. It may be subpoenaed as evidence by an attorney. It aids to check for deviations from facility policy or standards of care. Each health care provider is responsible for the accuracy of the pertinent details. Of note, medical records must be secured and high confidentiality is maintained.
Medical records analysis and summarization is of paramount significance in collecting the vital data relevant to the medical malpractice cases. The case focus details are extracted from the huge pile of medical records. The process involves exclusion of the irrelevant details and summarizing all the significant details in order to zero in on the case focus time period. It gives an overall picture of the enormous information contained in the medical records. Medical records are also essential in personal injury claims to substantiate the damages and to calculate the treatment cost. The future medical costs can also be calculated based on the progress of the patient and medical needs.
Medical records analysts must have wide knowledge and expertise about the different types of medical records and the charting methods. A good medical record analyst team will be able to provide all the key facts about the case and help the attorneys to attain an in-depth information about each individual case.
Our Expert team has undergone extensive training on medical records analysis and summarization. Our subject matter experts ensure maintenance of quality and accuracy in medical records summarization. We are HIPPA compliant and ensure data security.
Our quality work helps the attorneys to understand the case and settle the claims!!!