Medical record review & analysis (MRRA) can be a truth or consequences situation for the unwary attorney prosecuting or defending a medical malpractice case, workers’ compensation claim or vehicle injury case. It requires a legal medicine physician to provide an expert review and analysis of relevant medical evidence. The physician reviewer serves as a consultant or as a non-testifying expert witness.
Federal health care laws and initiatives have required hospitals to use electronic health record (EHR) systems. These systems are designed for health care providers to record patient information. EHR’s allow hospitals to verify that services were rendered for third-party payer audits. All information contained within EHR is discoverable.
HOW ARE EHRs FORMATTED?
EHRs are formatted to receive information from the physician, to provide content uniformity, to assist in the coding and billing functions, and for ease of medical record review by other providers. For example, a patient enters an emergency room and he or she provides identification to sign in. Once in the treatment room, the patient is first seen by nursing personnel to record past medical information, vital signs, allergies, current medications and immunizations into the EHR.
The next section of the EHR is for the medical provider to ask a series of questions. First, the physician asks the patient about his or her chief compliant (purpose and scope of the visit). Next are health care personal information (HPI) questions as to intensity of the problem, when it started, etc. This is followed by the review of systems (ROS) questions to survey each system of the body for any additional symptoms related to the chief complaint. The HPI and the ROS are audited by third-party payers for compliance.
Following this series of questions is the physical examination of the patient. The physician dictates the findings into the EHR for each body system.
The next EHR section is the medical decision making (MDM) area to record the findings of imaging, EKGs, lab tests and a brief description of the course of care during this visit. The last entries are the differential diagnosis (general causation of the illness), the medical diagnosis (specific causation), treatment or referral plan, and the disposition and condition of the patient upon leaving the hospital.
HOW DO WE START A RECORD REVIEW?
First, The Identity: Make sure that the medical record is for the correct patient. Ensure that there is a proper release of health care information (HIPAA-HITECH Compliant/Business Associate compliant) signed. I always ask for a copy of the person’s driver’s license to accompany the records to make sure all three documents match.
Second, If Wrongful Death Case: Make sure you are within the shortened statute of limitations. Ensure the estate executor is approved by the court and has signed for the release of medical records. Next, obtain a copy of the death certificate and supplemental certificate. Read both of them carefully as to the cause of death and compare it to the injury claim.
Third, Construct Two Time Lines: Make sure you have all the medical records. Obtain a copy of any medical records the patient has collected during their treatment. Set up a grid of events as reported by the plaintiff (time, place, persons, tests, surgery or treatments). Next, request a complete set of medical records from the providers before the start of the MRRA.
Once all the records have been collected, look for any changed information (doctrine of spoliation) and analyze the time lines, not only for good correlation of what happened, but to look for events that should have occurred but did not happen. For example, did the female patient have a pregnancy test before her CT scan of the pelvis?
Fourth, Size Matters: If you receive medical records that are less than 2 inches thick, consider yourself lucky. Simply start reading each medical encounter one by one from the first visit to the last. Analyze for acts, omissions and who assisted in the care or who should have assisted but was not there. If the records are many volumes, review the surgical reports and the discharge summary for each hospital admission for any care discrepancies with other EHR notes first. Always read the nursing notes and pharmacy orders for discrepancies with the physician’s notes.
Last, Putting It All Together: You must determine if the medical evidence supports or defends one or more cause of action at issue. Next, determine whether a testifying expert witness is needed and from which specific specialty. Having experts from too many different fields of medicine may invoke jury confusion.