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What are the processes involved in medical chart review


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The various processes involved in medical chart review have to be carefully executed to ensure completeness and accuracy which are vital to determining the validity of a legal case

Published in: Business, Health & Medicine
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What are the processes involved in medical chart review

  1. 1. Phone: (800) 670 2809 1What are the Processes involved in Medical ChartReview?Physicians and attorneys representing insurance firms have to reviewmedical records so as to make available accurate information for theverification and reimbursement of insurance claims. The various processesinvolved in medical chart review have to bemeticulously executed to ensure completenessand accuracy which are vital to determiningthe validity of a case. Medical record reviewcompanies in the United States are specialistsin the chart review procedure and offerdetailed and timely support services to meetthe needs of the medico-legal industry.The Medical Chart Review ProcedureMedical charting involves processes such as medical chart audit,organization of the chart chronologically and by category, checking formissing information, developing an analysis and summary of the chart, and atimeline of events.The reviewer makes a check list and conducts the medical chart audit toensure that the following information is available and complete: • Patient demographic insurance information sheet: this would include name, social security number, birth date, spouses name, address, phone numbers, insurance information, and so on
  2. 2. Phone: (800) 670 2809 2 • 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 treatmentAfter checking to ensure that all this information is available, the next stepin medical chart review is to arrange the information according to categoryand to develop chronologies and summaries. This involves: • Taking the chart apart
  3. 3. Phone: (800) 670 2809 3 • 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 recordThe organization of the medical chart helps the reviewer to identifyimportant events and create a summary and timeline.Expert Medical Chart Review Support Services for theMedico-legal IndustryMedical 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 ormedical record review would benefit greatly and save time and money byrelying an experienced service provider for support. Established outsourcingcompanies are equipped with a team of experts knowledgeable about theprocesses involved in medical chart review and can offer professionalsupport services to ensure accurate and error-free results. Reliable medicalrecord review companies offer competitively priced services in customizedturnaround time.
  4. 4. Phone: (800) 670 2809 4CONTACT MOS MEDICAL REVIEWS