A medical record is a collection of all a patient’s clinical and legal data from the time of their birth. A typical medical record has a patient’s vital health information, including diagnosis and treatment history, lab results, imaging scans, and other important information related to the patient’s care. It also includes notes written by physicians and other healthcare providers about the patient’s condition. Therefore, any reference to a patient’s health condition can be traced back to his medical records.
The importance of medical records in a patient’s life
A medical record is of critical importance in a patient’s life as it is a vital tool in providing accurate and reliable information about a patient’s health history. In addition, this data serves as an authentic and primary source of reference in many cases in a patient’s life journey.
For example, if a patient is fighting for his worker’s compensation claims, his medical record plays an instrumental role in verifying his claim. In such instances, insurance companies and personal injury attorneys review a patient’s medical record to decide on the claims. Unfortunately, these medical records often lack structure and organization, making them difficult to navigate.
Why is medical record management necessary?
In order to make well-informed decisions, it is essential for medical records to be kept organized and clear, as cluttered and unstructured information can lead to confusion. IMEs (Independent Medical Examiners), whose opinion forms the basis of resolving disputes arising out of the compensation claims are the ones who often deal with thousands of pages of unorganized medical records.
As a result, IMEs often find themselves overwhelmed when retrieving and interpreting crucial medical information from a vast volume of messy and missing data. Keeping medical records up-to-date and well-organized is an essential yet challenging task that can help reduce the time, stress, and costs of reviewing medical records.
Let’s closely examine the challenges in managing medical records data.
Challenges in medical records review management
Managing medical records can be arduous due to the sheer volume of data and documents that need to be organized. In addition, maintaining accuracy and ensuring compliance with various regulatory standards is critical in any medical records management system.
Some of the potential challenges in managing medical records are:
- Retrieval and sorting of medical records
- Deciphering medical terminologies
- Skimming and scanning the voluminous data
- Digitization of documents that are still on papers
- Decoding the physicians’ handwritten notes and medical short-Hands
These pointers very well explain the level of complexity involved in reviewing and managing medical records. It can be made simple and efficient by adopting some of the best practices to streamline the review process.
This blog will discuss the best practices for managing medical records review.
Best practices for optimizing medical record review management
An efficient medical record management system needs more than basic practices such as periodic updates and cross-verifying the altered medical data. Here are a few ways by which medical records management can be improved to ensure a smooth and hassle-free medical records review
De-duplication of medical records: It is estimated that medical records contain an average of 40% duplicate data. IMEs charge per page to review the medical records, which can add up quickly when multiple copies of the same data are encountered. Significant money is lost in reviewing redundant records. This is why the de-duplication of medical records is such a critical practice.
Nowadays, AI/ML systems are employed to remove duplicates from documents, which makes the process more effective and error-free. By removing duplicate entries in a medical record, organizations can quickly identify the needed information without sifting through unnecessary data. Also, it eliminates the need for manual review of medical records, thus saving time and money.
Medical records indexing: Indexing is of paramount importance while dealing with a large volume of data, which holds true in medical records review. The medical record is a combination of cluttered, unorganized documents, making retrieving medical information relevant to a specific case challenging.
Mixed pages of records are sorted and classified into doctor notes, RN notes, lab notes, radiologic data, call logs, utilization reviews, peer-to-peer reviews, declaration of custodian records, therapy notes, bills, aftercare visits, and a lot more. These reports are indexed, and the associated information is linked to each category respectively to make it quickly accessible for professionals.
Medical records chronology: One needs extensive knowledge of medical events and a good understanding of medical terminologies to be able to organize the records chronologically. A medical record is not truly organized until it is arranged in chronological order. This means that all the data related to a patient’s care and history should be sorted from earliest to latest, allowing professionals to easily trace their progress from one visit or episode of service to the next.
From the date of injury and cause of illness to diagnosis and medical treatments, all the elements in a medical record are organized step by step. A finely constructed medical chronology report reduces the time and minimizes the efforts to review the data.
Hyperlinking: Although the medical records are sorted and chronologically constructed, accessing specific document pages to pull out critical medical data is challenging. Like bookmarking, hyperlinking each set of reports in the records help to navigate and quickly access specific medical information.
When you apply these methods, you can be sure that the medical record review management is efficient and effective. Reviewers with access to concise and accurate record summaries can better evaluate, analyze, and cross-verify them to make informed case-related decisions.
PreludeSys has two decades of experience handling and managing medical records reviews. It leverages the latest technologies, such as AI/ML, and has manual expertise to review, summarize and organize medical recor