Missing Medical Records
How do you know as a legal nurse consultant that there are missing medical records? Are the medical records complete?
Although a copy of a certified medical record is supposed to be compared by the medical records custodian with the original, it is common for LNCs to detect there are missing medical records.
This often happens because of inattention during the process of copying the record, a task that is frequently subcontracted out to a records duplication service.
How to detect the fact there are missing medical records
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1. If you are working for a plaintiff attorney, and the plaintiff obtained medical records, compare the set the facility or doctor supplied with the one the plaintiff received. The facility may have withheld records from either the plaintiff or the plaintiff attorney.
2. Use medical record dividers to separate the sections of the record. You can do this either physically (with paper or plastic coated divers) or electronically using a documents manipulation program like Adobe Acrobat. First look to be sure that entire sections are not missing medical records.
3. Electronic medical records are usually numbered in the lower right corner with numbers like “1 of 346.” Look for gaps in the numbers.
4. Review copies of physician or nurse practitioner office billing and compare with the dates of the evaluations. Sometimes providers try to conceal the details of an office visit but forget that the billing records verify the patient was seen that day.
5. If possible, go the healthcare provider who produced the medical records and view them on site. A legal nurse consultant may do with a letter authorizing him or her to act as a representative of the attorney. If the records are to be reviewed on site, this should be promptly done.
Records are eventually put on microfilm and are more difficult to read than a hard copy. Each time I have done this, someone watched me looking at the original medical records and then eventually got bored and left me alone. You may be surprised at what you find. When one of my clients went to the hospital to look at medical records, he found another 600 pages the hospital had not turned over.
The attorney relies on you to detect missing medical records.
Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. Get more tips on how to overcome medical record traps by watching a replay of a webinar presented by Pat Iyer MSN RN LNCC: “Medical Record Traps and How To Overcome Them”. Get details at this link.