They need to go through all the documents in detail to use them as a key or supportive evidence and this consumes a lot of time. However, the road to victory is not as easy as it seems. Moreover, systematically-organized records make it easier for attorneys to review the documents in a fast manner. Attorneys must sort records in chronological order because otherwise, it can create confusion. Since medical records contain key information about a person’s health over a period of time, attorneys can use them as strongly valid evidence to prove their client’s claim and win the case. Due to improper or incomplete maintenance of medical records, there are high chances of losing trials.Ī detailed review of case-relevant medical records is highly important for attorneys and litigators, especially when assessing a medical or legal claim including medical malpractice, workers’ compensation, product liability, medical or insurance fraud investigations, etc. This is because even a small error can lead to inaccuracy and have legal implications. While handling a case that involves medical records, attorneys must study those records and completely understand the details while also checking for errors and mistakes. What is The Importance of Medical Record Review? Doing that will help not only patients and hospitals but also attorneys who handle medical malpractice and personal injury cases. Medical records are most commonly reviewed by medical facilities and centers for treatment planning and insurance claim purposes and by lawyers for preparing a case, especially for medical negligence or litigation such as personal injury.Īs these records are made up of documents about a patient’s medical history, it is vital to keep them well-organized. « Previous: 1.2.Medical record review is an essential process for ensuring the medical information’s accuracy and authenticity. Ensure that you are familiar and fully compliant with the guidelines of the Data Protection Act 1998 around the use and storage of all patient identifiable information.Ensure that sufficiently detailed follow-up notes and discharge summaries are completed to allow another doctor to assess the care of the patient at any time.Detailed postoperative care instructions.Antibiotic prophylaxis (where applicable).Identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials.Details of tissue removed, added or altered.Any extra procedure performed and the reason why it was performed.Names of the operating surgeon and assistant.The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. Ensure that there are clear (preferably typed) operative notes for every procedure.Any change in the treatment plan should be recorded. Ensure that a record is made by a member of the surgical team of important events and communications with the patient or supporter (for example, prognosis or potential complication).Ensure that a record is made of the name of the most senior surgeon seeing the patient at each postoperative visit.Ensure that when members of the surgical team make casenote entries these are legibly signed and show the date, and, in cases where the clinical condition is changing, the correct time.Ensure that all medical records are accurate, clear, legible, comprehensive and contemporaneous and have the patient’s identification details on them.Take part in the mandatory training on information governance offered by your organisation, including training on data protection and access to health records.Be fully versed in the use of the electronic health record system used in your organisation and record clinical information in a way that can be shared with colleagues and patients and reused safely in an electronic environment.In meeting the standards of Good Medical Practice you should: Surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained of all their interactions with patients.
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