Legal Nurse Consulting: Missing Medical Records

Doctor and Nurse Checking Medical RecordsHow would you know if the medical records you’re after are complete and no parts are missing?

While custodians of medical records must compare certified medical record copies against the original ones, it’s quite typical for LNCs to notice if there’s something amiss. This occurs because of the person’s inattention when copying medical records. If you’re a budding LNC fresh from completing a legal nurse consultant program, here are some tips to help you determine if the medical records you’re reviewing is complete.

1. Compare Documents

If you’re working with a lawyer and the medical records came from the plaintiff, check the records directly from the doctor or healthcare facility and compare them with the ones from the plaintiff. The doctor or facility might have withheld some of the records from them.

2. Check for Gaps Between Numbers

You could see the numbers of electronic medical records or EMRs on the lower right-hand corner of the paper such as “18 of 710” or “12 of 121”.

3. Utilize Dividers for Separating Record Sections

You could do this electronically with Adobe Acrobat or use plastic coated or paper dividers. But make certain that there are no missing sections first.

4. Whenever Possible, Get the Original from the Source

Go directly to the healthcare provider or doctor who created the medical records you’re reviewing. You could request the lawyer you’re working with for an authorization letter that enables you to act as his or her representative.

5. Look at Copies of Billing Receipts and Then Compare Relevant Dates

In some instances, health care providers attempt to hide the specific details regarding visits or treatment times but forget that billing records contain key details such as treatment dates and procedures a patient received.

Keep in mind that for many lawyers, medical records are just common electronic files or papers. Lawyers depend on your expertise to understand them and detect if anything is missing. In case you find that you’ve received an incomplete medical record, inform the lawyer as soon as possible so that they could decide if the missing records are crucial to the case or not.