What’s an Attorney to do Regarding Missing Medical Records? (Part 3/4)

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:

1. Organize the record chronologically with an index. This just makes sense. In an ideal situation you have electronic copies of all records, in chronological order with an index or table of contents that is hyperlinked so that you can click on the name of a record from the table of contents and be taken there. This is a service some LNCs provide (including myself).
2. Compare billing records to medical records- Are there tests or procedures that were billed for that you don’t see reflected in the medical record? Is there bill for wound care but you don’t see a note from a Wound Care Nurse? Do you see a bill for a blood transfusion but no signed consent and no documentation about the transfusion?
3. Create a Treater List:  A treater list is exactly what it sounds like- a list of the name of every single health care provider or facility (including imaging centers and pharmacies) mentioned in the medical record. Did the ER doctor state in a note that she referred the patient to the Neurologist Dr. Billings? Put Dr. Billings’ name on the treater list so you can make sure you have his notes. Did the doctor write in a note that, “the patient stated she was previously seen two weeks ago at Methodist Hospital”? Write “Methodist Hospital” on the treater list and make sure you have records from that hospital.​​

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.

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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?