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 management. (Legibility may have been a problem…) 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. Sometimes the information is actually erroneous!!! Yes, EMRs actually facilitate erroneous information and the propagation of erroneous information. Case in point: One of my family members recently had a 24 hour hospitalization. The patient had an IV in the right arm but the medical records stated “patient had a central line placement” – this was erroneous and let to the implication that the severity of the illness was greater than it really was. Only skilled clinicians can pick up and question these types of errors.
- 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. Studies done by outside sources may not be included in the record – e.g. a neurology consult may have been completed and faxed or securely electronically sent to the requesting provider. However, the text of the consult may not be included in the provider’s documentation – and the requesting provider’s record entry may NOT reflect the full implication of the neurology consult – only the specific portion that they were concerned about.
- Services used to be rendered by known or associate providers – e.g. Xrays – our radiologists were expected to render a complete report – stating normal findings, abnormal findings and surprise or additional findings. Now, many studies are outsourced and the interpretation of Xray studies is mostly: “No abnormalities noted”. I have personally had several cases where the “No abnormalities” did not fit with the clinical picture. Personally reviewing the Xrays found abnormalities that were not stated by the radiologist. I recently had a Lumbar Xray report on a patient with significant back pain. The report was “No abnormalities noted.” I reviewed the XRay and the patient had significant hip degeneration from aseptic necrosis. This led to a review of the Xray reading and a REVISED Report – and eventual surgical replacement of the hip for the patient and improvement of the back pain. We will review ALL rays!
- 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. These consults will often be limited to the question at hand. WITHOUT any reflective thought or considerations. This sometimes leads care into long and winding paths without much improvement! Clinical acumen and experience is needed to sort this out!
- We will start posting some information relative to medical aspects which will be of interest to attorneys and claimants. Check our new BLOG for the latest information!