Insights
Before we can discuss why medical records review is important in legal cases, we must first understand what a medical records review is, who performs such a review, and why it is vital to the outcome.
In the clinical setting, Clinical Documentation Improvement (CDI) professionals have a significant responsibility in ensuring that patient records are accurate and complete. By reviewing an average of 16 to 24 patient charts daily, CDI specialists help maintain the integrity of medical records, which is essential for continuity of care, accurate data collection, and proper reimbursement.
This article examines the role of CDI professionals, noting that it is quite intricate and demanding, and what guidelines and laws they need to adhere to in order to lawfully secure the proper documentation for an effective legal case – whether that be for the plaintiff or the defense.
These CDI professionals essentially act as medical detectives, piecing together information from various sources to create a comprehensive and accurate patient story. This involves:
Their work is crucial for maintaining high standards in patient care and guaranteeing accurate data for quality metrics and reimbursement.
CDI specialists must adhere to various guidelines and policies, including organizational bylaws, Uniform Hospital Discharge Data (UHDDS) guidelines, and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting. They must also adhere to internal documentation and coding policies. Their work impacts several key areas:
This process ensures that the medical record accurately reflects the patient’s condition and treatment, which is crucial for quality care and proper reimbursement.
Whether plaintiff or defense, preparation is the key to successful personal injury outcomes. Understanding the medical records process, where to request medical records from, and how to determine if medical records are missing or incomplete is only one component of the medical records review process in personal injury cases.
It is imperative that during the evidence gathering phase of a personal injury case, all relevant medical records, witness statements, and expert opinions related to the medical records are obtained.
Hospitals and insurance companies know that 99% of people don’t understand the complexity of the laws surrounding documentation compliance and coding and billing practices. That’s why a legal nurse consultant can help explain the importance, processes, and challenges of medical records review.
Medical records release is governed by a set of Privacy Rules (Standards for Privacy of Individually Identifiable Health Information) which implemented the requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").
HIPAA established what information was protected and what information was considered part of the medical records. Both medical and billing documentation are considered part of an individual's medical records. The Privacy Rules also established that an individual shall have access to their medical records when legally requested.
A HIPAA release form must be obtained from a patient before their protected health information is disclosed for any purpose other than those detailed in 45 CFR §164.506, which are specifically covered in 45 CFR §164.508 and summarized below:
In order to obtain medical records, an individual must complete and sign a HIPAA compliant medical release of information form. The HIPAA compliant medical release form must contain:
The HIPAA release form must also include statements that advise individuals of:
The HIPAA release form ensures that patients have control over their PHI and can specify exactly what information is shared, with whom, and for what purpose. This form is crucial for maintaining privacy and complying with HIPAA regulations.
Patients or their personal representatives have the right to revoke a HIPAA authorization at any time. The revocation must be in writing and will generally take effect immediately. However, there are exceptions, such as if the covered entity has already acted on the authorization in a way that can’t be undone, or if the authorization was required for obtaining insurance coverage.
The most common factors related to the medical records that can impact the final settlement amount of a personal injury case are:
An effective and efficient medical records review is where the expert evaluates the plaintiff’s healthcare records for legal purposes. A Legal Nurse Consultant can assist in obtaining the medical records and confirming their completeness. The accuracy and completeness of the records is crucial to assist in the determination of liability, causation, and potential compensation in litigation.
We would like to thank Pamela Hernandez, MBA, BSCJ, RN, TNCC, ENPC, CPC, FMC, LNC, for providing insight and expertise that greatly assisted this research.
Pamela Hernandez, MBA, BSCJ, RN, TNCC, ENPC, CPC, FMC, LNC, is a Medical Billing and Coding Analyst in J.S. Held’s Forensic Accounting – Insurance Services practice. As a registered nurse and healthcare consultant, she provides policy and procedure documentation review, healthcare consulting, expert coding and billing review, and legal nurse consulting expertise. She has held executive and leadership roles across multiple healthcare areas and is based in Texas.
Pamela can be reached at [email protected] or +1 512 885 1416.
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