Continuity of care and information are critical when reviewing a medical record. It all begins with the initial injury, but the continuum of information, evaluations and treatments travels through the entire medical record.
And, what first started out as a nice straight line quickly becomes a bowl full of spaghetti with plenty of nuanced twists and turns. It takes an expert’s eye and first-hand experience to follow these long, slippery strands.
Here are six tips to avoid getting tangled up yourself:
Look at each medical provider closely and on its own merit. Does the information at the beginning of the record hold true at the end of the record? This is particularly important for emergency department records. For example, did both the ER triage nurse and the physician get the same information?
Check for consistency: When a claimant or patient is seen by another provider, does the information about the injury, event or diagnosis remain constant and consistent or does it morph into something else? If information does not line up, then that should be a red flag for the attorney or adjuster that something – a crucial fact or piece of data – may be missing or even misrepresented.
Pay attention to shift changes: If you are reviewing an inpatient stay record, look closely at the change of shift documentation. Nurses report to other nurses when there is a shift change. Is the information documented by the receiving nurse the SAME as what had been noted earlier by the departing nurse? If not, that’s another red flag.
Track the ordering physician: When reviewing a diagnostic report, look at the reported diagnosis and ordering physician. Is this information consistent with other documentation? Sometimes you can determine that a new physician has been brought in on the case as that physician is the “ordering physician.” This is especially true for outpatient diagnostic studies. Remember: Consistency and continuity are key.
Examine what the injured party is reporting or describing to each provider. Is it consistent or does it change or grow? The information should be fairly consistent and make sense in the context of the alleged event and throughout ongoing treatment documents.
Follow the trauma timeline through the record. Look at timing and treatment, along with the associated responses. Did something new or different appear long after the initial injury? If so, is it a secondary complication or truly a horse of a different color?
This process can be daunting, especially for a non-medical person. That’s where Legal Nurse Consultants can help.
We are used to following that slippery string of spaghetti. From receiving a report from a medical colleague to documenting the reason for a test, a nurse typically does it all. LNCs take this invaluable work experience and overlay it onto insurance and legal files. We follow the pieces and make sense of that tangled mess.