Medical records are important not only to ensure appropriate care for the patient, but are also valuable legal documents in medical-legal litigation.

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Medical Record Features That Could
Impact Medical Record Review
Medical records are important not only to ensure appropriate care for the patient, but
are also valuable legal documents in medical-legal litigation. Comprehensive medical
record review services can help clarify the various medical aspects involved in diverse

2. www.mosmedicalrecordreview.com 1-800-670-2809
lawsuits including medical malpractice, product liability, workers’ compensation, and
social security disability.
Medical records may include handwritten or electronic clinical notes, scanned records,
emails, text messages, consent forms, oral correspondence between providers,
photographs, X-rays, MRI/CAT scans, lab results, printouts from monitoring equipment,
video and audio recordings and so on.
Key features of a medical record that could impact medical records review are -
Relevancy of medical records
A major concern is whether the medical records are relevant to the case.
 For the medical record analysis to be smooth, the documents should be relevant
to the case.
 A medical review company can help the attorney understand the benefits of
requesting specific medical records.
Accuracy rate
Accuracy implies preciseness and reliability of the collected data.
Accuracy rate is affected by key factors such as –
 the dependability of devices and equipment used for diagnoses
 the reliability of electronic systems used to gather, store, and share information
 the expertise of healthcare professionals in data collection and documentation
 access to prior medical records of the patient, and so on
Completeness of the medical record
Incomplete charts or missing records could affect the review process.
A complete medical record –
 contains sufficient data to identify the patient
 supports particular diagnosis
 validates the treatment and services provided
 clearly documents the treatment, care, and services
 facilitates the continuity of care

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Availability or accessibility
Disorganized records can slow down the record review process
 Accessibility may be affected if the documents are not organized properly
Timely documentation
Healthcare documentation must be completed in a timely manner.
Delay in documentation could –
 affect the care and treatment prescribed for the patient
 create more challenges for the reviewer
Reliability and legibility of data in the medical record
 The reviewer must ensure that the medical details are those of the concerned
patient.
 Legibility of the handwritten entries is a very important factor.
These medical record features could have an impact on medical chart review, its
accuracy, and the ease with which the review is done. A reliable medical record is one
that contains accurate information that helps identify the patient; and the
documentation should support the diagnoses and validate the treatments provided. The
medical record should be accurate, complete, well-organized, clear, legible, timely, and
authentic, if it is to facilitate medical records review and make it more efficient.