Medical Records: 10 Top Uses

Medical records have varied uses. LNCs are familiar with their role in evaluating liability, causation and/or damages. There are 10 other uses.

•  Various state and federal laws require that certain events, such as births and deaths, as well as certain diseases, be reported to public health agencies. Written medical record information facilitates compliance with these types of laws and regulations.
• Through the use of  statistical  analysis,  researchers can evaluate the compiled data to verify disease patterns or identify the need to establish new health outreach programs locally or globally.  Medical educators use actual case data to introduce their students to patient data as part of their initiation to disease, medical management, and evaluation of outcomes based on the facts presented in the medical record.
• The record is reviewed for documentation of billed treatments being completed on the patient’s behalf. As more claims are now being billed to Medicare and third party payors, it is imperative that no fraudulent billing occurs.  Civil and criminal penalties for fraudulent billing are very severe.  In an effort to comply with legitimate billing practices, specific processes have been implemented and trained staff hired by healthcare organizations and healthcare providers to review patient records and validate claims prior to submitting them for reimbursement.  Fraud investigators working for insurance providers or any federal or state operated programs complete detailed reviews of the medical record in an effort to detect cases of billing fraud and abuse prior to processing the claims for distributing insurance benefits.
• The data contained in the patient’s record capture the treatment and outcomes of the patient for each encounter with the healthcare team.  As a communication tool among the resources providing patient care, the patient care record facilitates continuity of patient care, not only for the current episode of care, but for future patient encounters.
• Most healthcare organizations are in a competitive market and seek to highlight their organizations’ services.   In an effort to justify existing programs and services or to plan for future outreach initiatives, these organizations are utilizing medical record data.   Post-discharge data analysis is important in identifying successful and financially feasible services.  It can also create an awareness  of  potentially  unsuccessful  endeavors.    Marketing  personnel  can assist the organization to build on their strengths and eliminate or redesign areas of weakness.
• Patient self-management is a reflection of today’s patient.  A growing number of patients have taken the initiative to assume more responsibility for their individual health efforts.    A by-product of this initiative includes understanding and actively participating in their healthcare.  Patients themselves are now becoming one of the main users of their healthcare information.
• Education encompasses utilizing the patient information to validate the clinical expertise performed by an individual.  Material collected from the record can be incorporated into educational sessions such as conferences and other types of formal or informal presentations.  Finally, this type of information is used as class material for educating students enrolled in some type of healthcare curriculum.
• Data obtained from medical records support research efforts in several ways,  e.g.,  to  complete  clinical  research,  create  new  products  and  drug therapies, and evaluate the value of technology in healthcare.   The medical record  is  reviewed  to  determine  whether  or  not  outcomes  of  patient  care achieved are appropriate.  It is also evaluated to calculate whether the care provided  was  not  effective  or  provided  in  the most  economical  manner. Healthcare information can detect potential risk factors for certain populations, form the basis for creating patient registries and databases for future contact and patient care encounters, and determine the financial feasibility of record systems.
• Public health and homeland security initiatives are indicative of today’s ever changing and fast-paced world.  Specific areas included in this area address the process of observing and reporting symptoms of disease or potential threats to the health of large segments of the population.  Data obtained from medical records also seek to detect any threat of bioterrorism.
• Patients and employers have additional needs as well.  Patients can verify the care provided and, as permitted under the HIPAA legislation, can also correct errors or inaccuracy of their records.  Employers use information obtained from the medical record to evaluate the potential for health and safety hazards within the organization, validate workman’s compensation or disability claims, and to process employee healthcare insurance claims.

Modified from Mila Carlson, PhD CLNC CNLCP Adoption Rates and Barriers to Implementation of Electronic Health Records in Physician Office Practices In Northwestern Illinois, Dissertation Presented to the Faculty of the School of Health and Public Administration, Warren National University  

Electronic Medical Records: How to Navigate Your Way Through the Paper Printouts.

In this one hour webinar you will learn: 1. To make sense of the maze of information in an EMR. 2. How to request the data you need through audit trail.s 3. How a healthcare organization’s use of EMRs makes it both strong and vulnerable. Sign up at this link for Electronic Medical Records: How to Navigate Your Way Through the Paper Printouts.