What are the Processes involved in Medical Chart Review?

Physicians and attorneys representing insurance firms have to review medical records so as to make available accurate information for the verification and reimbursement of insurance claims. The various processes involved in medical chart review have to be meticulously executed to ensure completeness and accuracy which are vital to determining the validity of a case. Medical record review companies in the United States are specialists in the chart review procedure and offer detailed and timely support services to meet the needs of the medico-legal industry. The Medical Chart Review Procedure Medical charting involves processes such as medical chart audit, organization of the chart chronologically and by category, checking for missing information, developing an analysis and summary of the chart, and a timeline of events.The reviewer makes a check list and conducts the medical chart audit to ensure that the following information is available and complete:

• Patient demographic insurance information sheet: this would include name, social security number, birth date, spouse's name, address, phone numbers, insurance information, and so on
• Consent to treatment: consent given by the competent adult for treatment for him/herself, especially surgery
• Emergency Department record: this should feature time and means of patient arrival, diagnosis and other conclusions at the end of emergency room treatment, whether the patient was sent home or admitted, and so on
• Order and entry forms for laboratory, special testing, and imaging: physician orders for lab and radiology tests, X-rays and scans
• General medical orders by departments: physicians’ and specialists’ orders on patient treatment
• History and physical examination report: history of treatment and medication; if the case relates to a specific incident, only the history relevant to that incident is necessary. The history and physical exam reports help to determine the appropriateness of treatment
• Consults for specialized care: specialist medical records of the patient
• Progress notes: physician and nursing notes provide an evaluation of the patient and a timeline of treatment and care – right from the time of admission to discharge
• Medication records: the type of medication, time, dosage and administration are examined as all this affects treatment

After checking to ensure that all this information is available, the next step in medical chart review is to arrange the information according to category and to develop chronologies and summaries. This involves:

• Taking the chart apart
• Grouping the chart into separate segments such as progress notes, radiology notes, physicians’ orders, nursing progress notes, and so on
• Arranging these segments in chronological order
• Clubbing all the ordered pages under one group
• Numbering the pages
• Making copies of the entire medical record

The organization of the medical chart helps the reviewer to identify important events and create a summary and timeline. Expert Medical Chart Review Support Services for the Medico-legal Industry Medical records and charts which are incomplete, poorly maintained, incomplete, inaccurate, and illegible can result in mismanagement of claims. Physicians or attorneys who need to perform medical chart review or medical record review would benefit greatly and save time and money by relying an experienced service provider for support. Established outsourcing companies are equipped with a team of experts knowledgeable about the processes involved in medical chart review and can offer professional support services to ensure accurate and error-free results. Reliable medical record review companies offer competitively priced services in customized turnaround time.