ALN’s Legal Nurse Consultants are experienced at reviewing records and creating reports for our clients that result in measurable, positive outcomes in legal cases. However, new Legal Nurse Consultants often have questions about getting started reviewing a medical record. There are concrete steps for a nurse to take to successfully review a medical record, and so we revisit that article with an update. Should a new Legal Nurse Consultant be interested in other steps to get started in the field, check out the ALN post How to Become a Legal Nurse Consultant. Nurses have such specialized knowledge of the inner workings of medical care that they possess abilities in medical record review that other members of the legal team likely can’t reproduce.

When using medical records to build a claim or defense, legal teams must have these documents requested through a specific process. In order to aggregate enough information needed for a particular case, analyzing these records can prove to be challenging and overwhelming. However, understanding how to review medical records is a cornerstone of their profession, and legal nurse consultants can successfully navigate this process using their familiarity and expertise.

Request the Relevant Medical Records

Requesting medical records begins with identifying the relevant documents for each case. A legal nurse consultant can easily recognize which records directly apply to the case and will be useful for review by identifying known health care providers and facilities. During the course of the review, additional providers may be identified and those records should be requested if it appears they are pertinent to the case. When the defense requests medical records, a subpoena may be needed to receive the certified documents. In cases related to certain specialties, records such as fetal heart monitoring, HIV testing, and photographs or video must be requested specifically. The legal nurse consultant also ensures the request for medical records follows HIPAA regulations before completing and signing the request. To get more info on how to request your medical records, read ALN Consulting’s blog post, How to Get Your Medical Records.

Organize the Medical Records

Upon receiving medical records, a legal nurse consultant organizes the documents and performs a preliminary analysis of record completeness. The record is bookmarked electronically by section and prepared for Bates stamping. Bates stamps, or Bates numbers, annotate the documents by page number and are usually preceded by letters that denote the provider or facility from which the records originated. There are many programs that will easily Bates stamp records electronically, including Adobe Acrobat.

Depending on the type of clinic, hospital, or facility records the legal nurse consultant reviews, different sections are expected. For instance, a complete long-term care chart includes the following sections:

  • Fact Sheet
  • Discharge Summary
  • Physician’s Orders
  • History and Physical
  • Physician’s Progress Notes
  • Consultations
  • Graphic Records
  • Nursing Admission Assessment
  • MDS (Minimum Data Set)
  • Care Plans
  • Interdisciplinary Care Plan Meetings
  • Nurses’ Notes
  • Nurses’ Assessments
  • Activities of Daily Living Flow Sheets
  • Medication Administration Record (MAR)
  • Treatment Administration Record (TAR)
  • Labs
  • Social Services
  • Therapy Notes
  • Respiratory Therapy
  • Nutrition
  • Consents
  • Transfer Forms

A hospital medical record may include:

  • History and physical
  • Orders
  • Progress notes
  • Lab reports (including contract lab)
  • Progress notes
  • Vital signs
  • Assessments
  • Consults
  • Clinical reports
  • Authorizations and consents
  • X-rays
  • Images
  • Fetal strips
  • Videos
  • Pathology slides
  • External records referenced for patient care: other provider records, records provided upon transfer
  • Patient-generated records
  • Personal health records

Organizing the medical records allows for early identification of missing records and quicker, more efficient analysis. In addition, organizing the records is a valuable service to the legal team and allows for the entire team to find specific data and reports in identified records in a short amount of time.

Critically Analyze the Medical Records

After being organized, the medical records should be reviewed in relation to the particular case or filed complaint. This analysis should focus on any known case issues, as well as other areas of concern appreciated by the nurse reviewer. Any required chronologies or timelines are completed concurrently with the review. For further detailed instruction on specialty timelines, see Alicia Davis’ article in the American Association of Legal Nurse Consultants Journal of Legal Nurse Consulting. Although the reports should be thorough, many aspects of the medical record are immaterial and therefore should not be included. When the review is finished, the timeline should be edited for relevancy, with only information pertinent to the claim noted in the reports. The benefit of hiring a legal nurse consultant is that a nurse can sort out what is relevant to the case and bring out crucial details among the millions of data points in a medical record.

Identify Medical Experts and Assist Legal Counsel in Retaining Qualified Experts

As a legal case proceeds, it may be necessary to identify what type of expert opinion will bolster the case. A legal nurse consultant can assist in determining the specialty of expert needed and how to find the most qualified and experienced testifying expert to opine on the case. Requirements for experts vary from state to state, and in some states an expert must be a practitioner licensed in that state, practicing in the area of opinion at the time of the alleged breach in the standard of care. It is important the legal nurse consultant familiarize themselves with the requirements in each applicable state when searching for a qualified testifying expert. In addition, in some states, the legal nurse consultant performing the initial records review can testify as a “fact witness” based on knowledge of the chart. Nurses also testify regarding costs and billing, and Certified Life Care Planner nurses can create life care plans and testify to damages. ALN Consulting has published a blog article on Identifying Medical Malpractice Expert Witnesses.

Re-evaluate Medical Record Requests

Legal nurse consultants often receive requests that are partially fulfilled. During the review process, the nurse consultant will note all missing records and make a list of illegible records, as well as records that are suspicious for fraudulent documentation, to include in the next round of request for records. Because of their expertise, legal nurse consultants can quickly identify missing documents and records needed for further examination which should be requested.

While obtaining and analyzing medical records can be complex, legal nurse consultants assist legal teams by requesting relevant records, identifying any missing or fraudulent documentation, and reducing the massive volume of records down to the most compelling evidence. A good legal nurse consultant provides insight and perspective on the influential aspects of the records, giving the legal team solid support in their claim or defense.

Want our legal nurse consultants to assist you in your case workup? Contact our Experts.

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