Discerning what particular information is relevant and important in medical chart notes can be a time-consuming and difficult process, especially for individuals who are not accustomed to reading documentation specific to health care. Nevertheless, reading chart notes is often a necessary component of developing a legal case. Two out of the three most frequent allegations against nurses in medical liability claims involve errors or omissions in documentation. Establishing a methodical system for reading chart notes can help individuals navigate these documents in a more efficient, successful manner. In this blog post some practical tips for efficiently reading medical chart notes will be presented.
- Keep in mind the purpose of the chart review
Look for evidence in the chart to support or deny the elements of the claim. Important elements that can often be found in medical charts include the date of injury, causation of the injury/illness, patient diagnosis, treatment providers and dates of treatments, treatment plans, and prognosis. Next, conduct research on the diagnoses and body systems that may be related to the claim. Begin with a simple Google search, and then expand depending on the issue.
- Have go-to sources for medical terminology, abbreviations and best practice
Knowing where to quickly find the answers to questions you may have regarding medical terminology, medical conditions, and abbreviations can be a valuable resource. There are combination sources such as Medilexicon.cm, which offers multiple features in a single source such as medical dictionary, common abbreviations, and drug information. Patient education materials published for various conditions, diseases, and medications may also be useful resources, since these are typically written in terms more easily understood by the general public.2
Once you have completed the basic search for terminology and abbreviations, it is necessary then to analyze the records to determine any potential deviations from the standards of care. This requires research into the industry standards and best practice – from authoritative literature and texts as well as national specialty organizations.
- Utilize software systems such as Adobe Acrobat Pro to enable Optical Character Recognition
Optimal Character Recognition (OCR) allows a computer to recognize text within image documents such as uploaded medical records. Having access to text-searchable medical records significantly increases the rate at which information being sought after can be found compared to performing manual searches.3This technology is especially useful when there are many medical records from numerous medical professionals that may contain useful information to be used to support a particular claim, or when medical records are initially provided only in print form.
Now that you have been made aware of some strategies to improve the efficiency of reading through medical chart notes for legal purposes, you should feel more confident in your ability to manage this process. Keep in mind that there are many ways to successfully read and analyze medical chart notes, and so it is important to find which strategies will work best for you. If you continue to struggle with I reviewing, interpreting and analyzing medical records on your own, Integrity Legal Nurse Consulting PDX can help. Our work is to help our attorney clients so they understand all potential issues in their client’s medical chart notes.
- Professional nursing documentation. Rn.com. https://lms.rn.com/getpdf.php/2163.pdf. Published December 31, 2015. Accessed January 6, 2019.
- Sisco-Beck, L. Medical records 101: Because sometimes a law degree just isn’t enough. Americanbar.org. https://www.americanbar.org/groups/young_lawyers/publications/the_101_201_practice_series/reading_medical_records_101/. Published August 9, 2017. Accessed January 6, 2019.
- OCR Admin. Healthcare: How are you getting that data into your big data model? Cvisiontech.com. http://www.cvisiontech.com/blog/2018/02/15/ocr-software-healthcare-big-data/. Published February 18, 2018. Accessed January 10, 2019.