By Kari Williamson
There is no truer axiom. It applies to virtually every aspect of life. If you are unaware of a situation or unsure about information, then you are unable to fully analyze or even completely question the issues at hand.
This is doubly true when reviewing medical records. If you don’t know to look for something or you don’t know what to look for, how will you find it? Blind luck? Maybe you will get lucky enough to find part of the information.
But, now what? Do you know what to do with the nugget of information you just stumble upon? Are there secondary or tertiary pieces of information that affect your newly found nugget?
In reality you may never know.
Can non-medical readers “find” things in the records? Of course they can. Can non-medical personnel review a medical document? Again, of course. It happens every day.
But the bigger question is, do they understand what they have found? And, even more important, how do you use it to build a solid case?
Do you understand that perhaps you have only partial information? Or does that nugget lead to a HUGE vein of information? Are you really clear on what to do? How do you find other tidbits that you can build on?
Here are half dozen best practices based on my training and experience:
- Look for consistencies and inconsistencies within the record. Follow information reported in the history, physical exam and radiological studies through the record. See if it holds up. Or, does the information change or morph into something else?
- Dig into pre-morbidities and pre-existing conditions. How do they play into the scenario?
- Look at the event timeline carefully. I mean really carefully. Look at dates, times, providers names.
- Are there gaps in the timeline? Holes in the timeline allow for missing records and new events that could influence your injury/claim.
- Cross reference all sources of info against each other. Nursing notes, radiology studies, physician notes, therapies and other data should be crossed referenced for similar or dissimilar information, diagnosis codes, etc.
- Don’t be fooled by a small volume of records. There could be lots of missing records.
And when things still don’t add up, reach out to qualified LNCs and physicians to help investigate, analysis and piece together the puzzle. You just might strike gold!
Kari Williamson, BSN, RN, LNCC, CCM is a Legal Nurse Consultant with MKC Medical Management. Contact Kari at firstname.lastname@example.org or 865-551-6800.