Information and FAQs:
Why it is necessary to have a seasoned physician review medical documentation:
- Medical records are different now than they were 10 years ago and the implications:
- Medical records used to be concise linear documentation for clinical care rendered by the performing provider – they may have been 1 to 4 paragraphs of text narrating findings and thinking and care managment. NOW, they are a hodge podge of data points strung together by often different providers. The new records are wordy and repetitive and often the relevant information is embedded in 1 or 2 sentences.
- Medical records may not be fully representative of patient information and patient care now:
- Most patients had a “family physician” who rendered and directed their health care – therefore the records were fairly complete and notated or referenced all of the clinical studies and consults as they were necessary for patient care. NOW, care is fragmented. Care is rendered in different facilities and different locations and they may not fully share patient data. Patient centered medical homes (PCMH) do a little better in coordinating and documenting care but often are still lacking.
- Electronic documentation has led to lots of E mails and electronic data which, although relevant to medical care, may not make it to the actual text of the medical record.
- Services used to be rendered by known or associate providers – e.g. Xrays – our radiologists were expected to render a complete report. Now, many studies are outsourced and the interpretation of Xrays is “No abnormalities noted”.
- Consultations with medical specialists are not always as informative as they used to be because consults are now being done by mid level providers for the consulting physician. The mid levels often follow guidelines of care – while not a bad thing, they may prolong the acquisition of definitive diagnosis or definitive care.