Medical Legal Consulting News, May 2018
IN THIS ISSUE:
- EMR Increases Volume of Medical Records
- MLCS Tightens Up Analysis
- Significance of Routine Medications Quiz
After a hiatus, we are bringing back the MLCS newsletter as a way for us to share with you the trends we are seeing in the review of medical records for all types of injury cases. We hope you enjoy our story this issue about the impact of electronic medical records (EMR) and how MLCS is adapting our reports to concisely communicate our findings.
The good news is that MLCS nurse consultants have been completing medical record reviews for over 27 years! We have the depth of experience to react to trends, and adapt our reports to continue to deliver the key points you need.
I am indebted to the nurse entrepreneurs who identified the perfect match between RN knowledge and clinical expertise to help claims handlers and attorneys to understand medical records. Part of my role as Director at MLCS is to mentor the next generation. Join me in congratulating Jeanine Hinkle as our Assistant Director of Consulting Services and welcoming Heather Jordan as our newest legal nurse consultant.
We appreciate your business! Check out the updates to our website and please feel free to contact me or Jeanine with any questions or concerns.
Linda Luedtke, RN, MSN
President and Director of Consulting Services
EMR Increases Volume of Medical Records
One very noticeable trend has been the growing number of pages of medical records, which appears to be largely the result of electronic medical records (EMR). Some of the increase stems from EMR formats that extensively document normal or routine assessments, or have autofill properties in which lab and diagnostic report results are repeated.
Two years ago, our average medical record review assignment was about 800 pages. Currently, the average medical record assignment in our office is about 1,200 pages. We are happy to report that our time to complete a review has not correspondingly increased. MLCS nurses are experts in reviewing all formats of EMR and can easily recognize the duplicates and get to the new information.
MLCS Tightens Up Analysis
In an effort to help clients hone in on relevant information quickly, we are tightening up the analysis portion of our reviews—working on ways to concisely present the nature and extent in injury, and the allegation-specific strengths and weaknesses.
Along with this, our nurse consultants are highlighting the most relevant facts within the chronologies. We also identify missing and incomplete records within the chronology and analysis, and provide a separate missing records list.
See how MLCS can help with an expert medical records review >>
Significance of Routine Medications Quiz
MLCS nurse consultants have long been aware that the routine medication list included in the medical record can provide clues to chronic and pre-existing medical conditions. Changes from one date of treatment to the next can be helpful in identifying missing records. For example, a change or addition of a new rheumatoid arthritis medication between primary physician and orthopedic visits may be an indication of a treatment with a rheumatologist.
Another concern with evaluating the significance of medications is being aware of the number of medications that may be prescribed for very different conditions. For example, tricyclic anti-depressant amitriptyline may be prescribed for chronic pain or sleep.