By Debra West, RN, BSN, CCM, LNC

Medical records are often incomplete. Office notes, hospital records and even test results might be missing, leaving gaps in treatment.

Yet, in order to have a clear picture of the claimant, the injury, medical treatment and diagnosis, we must have all of the  records.

The first step in an effective assessment of medical records that relate to an injury is to establish 1) what records we have and 2) what records we don’t have – whether they were purposefully omitted or not.

The first step in an effective assessment of medical records that relate to an injury is to establish 1) what records we have and 2) what records we don’t have – whether they were purposefully omitted or not.

The problem

With me and others trained to assess injury claims, red flags immediately go up when I discover the records are incomplete.  That’s because missing records may contain valuable information regarding the injury.

They often hold the key to the relationship, if any, between the Mechanism of Injury and the alleged injuries. Records may be purposefully omitted which define preexisting illness/injuries or even date the injury to a much earlier or later time.

When records are submitted, we assume they are complete.  However, this is rarely the case.

Best practices

When reviewing the records pay close attention to the page numbers.  This is frequently the first clue of missing documents.

Next, look at the dates of service on the billing and compare the dates with the records received. Occasionally an office note will refer to an earlier appointment, which is another way to check for completeness.

Bottom line

The reviewer must have a complete set of records to accurately assess the reported injuries, the Mechanism of Injury, pre-existing pathology and if there is a relationship between the alleged injuries and the event.  Rendering an opinion without full assessment of the file can lead to costly acceptance of claims, which possibly could have been diverted if the records had been complete.

Debra West, RN, BSN, CCM, LNC is a Legal Nurse Consultant with MKC Medical Management.  Contact Debra at 865-551-6800 or debra@mkcmedicalmanagement.com.