Every time we visit a doctor’s clinic for a consultation, we may notice that the physician dictates a medical note covering the aspects of the visit. These dictated notes and other documents such as lab reports are logged into the Electronic Medical Records (EMR) for need-based access in the future.
The connection between Electronic Medical Records and Medical Records Review (MRR) is an interesting discussion in the medical record review sector. It is worth exploring the intricacies of this connection to understand how patients can be helped through this connection.
EMR – What Is It?
Electronic Medical Records is a storehouse for patient’s health information (PHI) which includes but is not limited to the following information:
- Patient demographics including name, address, phone number, fingerprints, etc.
- Notes dictated by the medical professionals such as physicians and assistants
- Diagnostic studies: X-rays, MRIs, CT scans
- Peer-to-peer review reports: communication between healthcare providers regarding the patient’s medical condition
- AME/QME reports from Workers Comp injury lawsuits
These documents are stored digitally in a medical repository at a single location and can be accessed by the patient at any time.
Old Paper Records and the challenges to store them
Hospital staffs scan old paper records that are part of the patient’s past medical history and load them into the EMR. This includes the transcribed notes and rescue squad reports written by the medical assistants.
Some old paper records are in a worn, deplorable condition, making it difficult to scan the documents. Capturing the contents of a poorly hand-written note is another challenge for the people involved in the scanning exercise.
Benefits of Unification
Integration of all the medical documents, both old and new, into an EMR helps the patient save time and effort to obtain copies of medical records, rather than visiting all the healthcare facilities he or she had been to.
The connection between Electronic Medical Review and Medical Records Review
Medico-legal Collaboration
When legal entities seek to investigate and fix the responsibility in a patient’s case regarding an injury or a medical condition, the documents stored in EMR become the primary focus of the investigation. These documents provide significant insights into the patient’s health status relating to the case probed.
In case of an insurance denial or an injury in the workplace, the patient gives the attorney representing the case access to EMR documents. These medical records are reviewed by the medical record reviewers chronologically and presented as a summary to the attorney.
Medical Auditing, Insurance Underwriting, Coding and Billing
Our medical records are used extensively for the vital process for healthcare systems to evaluate treatment outcomes and patient satisfaction. A medical record review for medical audit covers such things as past medical history, surgical history, medications, dosages, vital signs, lab values, and cancer stages.
Insurance agencies use the patient’s electronic medical records to identify risk factors such as drug abuse, sexually transmitted diseases such as HIV, and family history that could be detrimental to the patient’s health.
Coders and billers also utilize the documents stored in the electronic medical records for coding and billing purposes.
A Summary that Stays Relevant to the Cause
A trained medical record reviewer understands the purpose of the reviewing medical records and provides an abstract of the patient’s voluminous medical documents. The summary must be user-friendly and easy to read and comprehend for the assigned attorney. On the other hand, in the case of medical auditing and insurance underwriting, the needs are different. The writer or the medical auditor understands the medical terms used and does not need oversimplification.
Why PreludeSys?
Since law firms and insurance companies do not have enough time to conduct extensive reviews of the medical records, they prefer to outsource these tasks to gain relevant insights while staying cost effective.
PreludeSys is an ISO 2701:2013 certified company and has been a leader in the medical records review industry for more than two decades. We provide comprehensive medical records review for the purposes discussed here and for other related use. In addition, our reviewers possess hands-on experience delivering stellar summaries that assists the attorneys in medico-legal cases. Our services also include:
- Scheduling process – the collection of medical records from the medical repository
- Medical record indexing with hyperlink handles to help the attorneys navigate to the particular document
- End-to-end data encryption to ensure data security
- HIPAA compliance
Conclusion
Medical documents are the chronological lifeline of a patient’s health, and electronic medical records (EMR) act as a storeroom for these life-saving documents. Medical record reviews and summaries go hand in hand to resolve medical disputes. Also it helps the patients to receive proper medical care from the healthcare facilities and adequate compensation from a lawsuit.
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