Early on in my medical career I had top notch consultants available to help me even though I was in a rural area in Maine. I remember my lawyer advising me – “don’t ever forget to write your notes and put in some indication of what you are thinking”. Interesting statement, but after some discussion, my lawyer told me “if there is nothing in the record – I have nothing to work with – if there is something to indicate what you are thinking – then we have a position to go from. You don’t have to write everything but make sure there is something to indicate your thoughts.” Over the years I have learned to include information in my records about my thoughts so that they can be clear to my lawyer, the jury and the judge. This is also helpful when others are providing care for the same patient. That is just how I learned to function in my practice and it has worked very well. Fortunately, I have not needed to test this in court.
This was easy when I started my career and medical notes were hand written, typed or dictated. The thoughts expressed were coherent and flowed. The advent of EMRs brought about the era of many mouse clicks with bits of information which may not be connected very well or at all. Some providers get paid by the mouse click! Additionally, “copy forward” has its own set of issues – including erroneous information being copied forward! I used to review copious EMR records from Boston Hospitals that often ranged hundreds of pages. Once I learned the “templates” it became easier as the real information and thought processes entered by the provider might be contained in only 1 or 2 sentences. I just had to find them!
Reviewing medical records today is more difficult due to EMR issues. Additionally, the flow of care may not be stated outright but may be abstracted from the information contained across several EMR notes. Some information may not appear relevant but within the context of the review, it may be highly important. These are some of the reasons that seasoned providers should do medical record reviews in any complicated cases.
If you have clients and need medical information and / or direction, consider involving a seasoned physician to review the records so that you can get up to speed quickly and your client can have ALL their issues addressed!