Missing pieces of the medical record are not necessarily a sign of fraud. There are many reasons certain records may have been left out, the most obvious of which are probably that either some information was missing from the record request form or the (non-clinical) person compiling the record made a mistake. These are discussed in detail in part II of this four-part series on Missing and Altered Medical Records.
When trying to identify missing medical records and overcome the barriers associated with missing records, clinical and practical understandings of hospital policies and the standard of care are so important. This a huge area of opportunity for Legal Nurse Consultants to really shine. A nurse who has been in the trenches working with patients will know what tests this patient should have had and will be able to recognize when they are missing. He or she will know what documentation should be present in a variety of clinical situations and may be able to help formulate record requests to help you get exactly what you need.
Shameless plug- Obviously as a legal nurse consultant and business owner who believes in the value of what I do, I’m going to tell you that I, or someone like me, is going to be your best resource for identifying deficiencies in the medical record. As someone who has had to document in a chart and audit charts of my peers I know how to look for what’s missing in documentation. Working as a nurse, this was self-preservation- I needed to my sure there weren’t deficiencies in my documentation so that I was covered if something went wrong.
But if you still aren’t ready to work with a legal nurse consultant, here are a few tips to get you started on your own:
Interested in learning more? Pettigrew Legal Nurse Consulting Services is proud to announce our approval for one CLE hour by the Georgia Commission on Continuing Lawyer Competency of our course: Missing and Altered Medical Records: Developing a Clinical Eye for Deficiencies in Medical Records. Reach out today to schedule your Lunch and Learn (in-person sessions available at your office within one hour of Canton, GA. Virtual Lunch and Learns can also be arranged. Click here to contact us.
This was a long post, but I hope it helps you overcome some of the difficulties associated with identifying and obtaining missing pieces of the medical record. Although this post mostly dealt with things that are left out by accident, Part 4 of this Four-Part series on Missing and Altered Medical Records will deal with records that have been intentionally altered. It will be up soon!
What other issues have you come up with when medical records are missing? Comment below!
Other parts of this series:
Part I Introduction
Part II Why Do Parts of The Medical Record Go Missing?
Part 1 of this series is available here.
It’s obvious that having incomplete medical records on hand can break your case, so why are incomplete medical records so common? It's important to note that in most cases in which portions of the medical record appear to be missing there is likely a reason for it that doesn't involve fraud, but that doesn't make your situation as the attorney receiving the records any easier.
Since the implementation of Electronic Medical Records (EMRs) in the vast majority of health care facilities, one would think it would be easy to just print the whole record out (or- more likely these days- save everything as one PDF) and have everything at your fingertips. Unfortunately that isn’t always the case. In the rush to become compliant with the Patient Protection and Affordable Care Act (PPACA), HITECH and other information systems legislation of the early 2000s implementation of a comprehensive and purely electronic medical record is still something we’re only dreaming of.
One huge barrier to a comprehensive medical record is that people have a tendency to go doctor shopping. If they go to one doctor and don’t like the diagnosis or proposed plan of care they just switch to a new doctor. In many cases they don’t even keep track of which doctors they’ve been to for what condition. In my experience as an ER nurse we would even get patients who would go to one ER and not like what they heard and then go stand across the street from the hospital they just left and call 911 for an ambulance ride to another hospital to try and get a “second opinion.”
But let’s say we have a unicorn- a compliant patient named Ms. Mabel who gets all of her health care through one large health care system so everything is all in one place and in one EMR. Her PCP, surgeon, pharmacy and specialists are all using the same EMR. Will you, as the attorney, still receive 100% of the patient’s medical record when you request it?
Unfortunately the answer is “probably not,” and there are several reasons why this might happen.
Point-of-Care labs and other tests. Point-of-Care tests are tests done at the bedside with the patient. One of the most common is blood glucose in people being monitored for diabetes but heart enzymes, certain urine tests, EKGs and others can be done at the bedside as well. Sometimes the nurse gets the result as a read-out on the screen and sometimes there’s a print out that will supposedly get scanned into the medical record eventually. Some companies have come up with ways to interface their point of
care testing machines with the electronic medical record, which is a leap forward for technology- when it works the way it's supposed to.
Other labs must be sent off for testing. Send off tests can be incredibly frustrating for the healthcare provider. Unfortunately most- if not all- hospital labs don’t have the capability to keep the equipment and supplies needed for 100% of the tests that might be ordered on a patient on site. You may remember that in the earliest days of the Covid 19 pandemic there were many hospitals and offices that had to send their specimens off to the CDC and wait days for results. This happens with a lot of other types of tests too. This can lead to the results not getting entered into the patient record in a timely fashion or to the results being entered in an incorrect part of the medical record, especially if the patient is discharged from the facility or transferred to another part of the hospital before the results come in.
Imaging done at other facilities. This wouldn’t apply in the case of Ms. Mabel because she is the one patient in the world who gets everything done in one place, but for many real patients this is the case. The patient may go to any number of outpatient facilities for MRIs, CT scans, ultrasounds etc and then a radiologist (who may even be working remotely out-of- state) reads the scans and makes the report. Now the physical image is one place, the report is coming from another and we just have to hope both make it back to the patient’s chart without getting separated.
Jumbled records. Even when all of the records come from one facility they may not have been printed or bound in order. Many EMRs have slightly different charting systems for different departments (such as ER, radiology etc) and the person compiling the medical record may not have the ability or inclination to streamline them for you.
There are plenty of other reasons you may be missing significant parts of the your client’s medical records, but it’s time to get to meat of the matter- What’s an attorney to do? I cover that in part three (coming soon).
I'm Jennifer Pettigrew and, true story, I first became interested in Legal Nurse Consulting after my auto insurance company was sued following a car accident in which I was found to be at fault. I wasn't sued until after the statute of limitations was up but an exception was made and the plaintiff alleged that because of being rear-ended he was on pain medications chronically which caused him to develop diabetes and become blind. As a nurse I knew that Diabetic retinopathy cannot develop over the course of just a few years but rather is a complication that develops after several years of untreated or poorly treated diabetes. The case was settled by the insurance company before ever going to court for several million dollars, but from that point on I have been interested in the difference medical professionals could make in legal proceedings.