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?
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.