Chart Reviews

  • Elementary, my dear Watson!

    25 July 2013 / California Workers Compensation, Chart Reviews, Cloud Based Computing, Impairment Physical Exam, Impairment Rating Specialists, Medical History, Medical Technology / Comments Off on Elementary, my dear Watson!

    There’s a new cloud-based computer service that takes in patient information and then spits out useful results in record time. And no, I’m actually not talking about RateFast. Did you catch the 2011 Jeopardy special where Watson (IBM’s language savvy super-computer) competed against two former Jeopardy champions? The AI system out-answered—or rather, out-asked—both of its human opponents, and won $1 million in prize cash.

    But Watson’s verbal talent is now taking on questions that are tougher than those Alex Trebek would ask: the computer system is diagnosing and generating treatment plans for cancer patients. An agreement between IBM, healthcare company Wellpoint, and Memorial Sloan-Kettering Cancer Center is going to make Watson’s thinking power available to hospitals and clinics around the nation.

    Here’s how it works: you’re a doctor, and you need to write a treatment plan for your patient, but you’re stretched for time, knowledge, resources—or maybe you just want a second opinion. So you log into Watson using an app on your tablet or computer, and you enter your patient’s medical situation. Within minutes—usually within seconds—Watson gives you a series of treatment plans based on the latest medical research, and each plan is ranked by its expected effectiveness and cost.

    Over the past few years, Watson has become an expert oncologist. According to an article at Wired Magazine, Watson needs only a few seconds to search through “600,000 pieces of medical evidence, more than two million pages from medical journals” and 1.5 million patient records. Wellpoint clams that Watson can correctly diagnose lung cancer 90% of the time, as opposed to the relatively paltry 50% correct-diagnosis rate of a human doctor.

    For now, Watson’s expertise is restricted to lung, prostate, and breast cancer, but the computer never stops learning. It’s difficult for doctors to stay abreast of the current medical research in their field, but Watson can “read” the results of new studies as they’re published, and instantly apply the information.

    The Memorial Sloan-Kettering Cancer Center in New York says that it would take 160 hours of reading a week for a doctor to stay current on all new medical knowledge as its published—and that doesn’t even account for applying that knowledge (or taking care of tedious clerical work like filling out PR-4 reports). Obviously, no human medical worker can do what it takes to know everything about their work. But Watson and computer systems like it are unencumbered by the human weakness of, you know, having a life.

    The goal is to have computers crunch numbers and negotiate the rules of today’s labyrinthine healthcare system, while medical professionals can leave work on time. Watson could be a major wave in medical technology’s recent move toward cloud-based apps that aim to streamline productivity around hospitals and clinics.

  • Discuss Your Clinic's Work Note with the Employer

    09 January 2013 / Chart Reviews, How To / Comments Off on Discuss Your Clinic's Work Note with the Employer

    Take a close and critical look at the format of your clinic’s work note. You will find that some employers have their own form for administrative reasons. This is sometimes an unavoidable situation.

    You may find a maze of confusing options, or options that very slightly with poorly defined terms and time frames. In a poorly designed employer work status note, I will often look for the comment sections, and write in common sense limitations as outlined above. I may also reference my clinic check out functional instructions.

    The most important issue, however, to have a clear discussion in advance with the employer so they understand your philosophy of return to work policy, and become familiar with the practice’s policies.

    Educate the employer on why “time weighted” instructions are used and their practical application.

    Communicate the common goal of returning the injured worker to the workplace under any reasonable circumstances.

  • My Boss is Not Following the Instructions

    26 December 2012 / Chart Reviews / Comments Off on My Boss is Not Following the Instructions

    “My boss is not following the instructions” -- is common feedback on the follow up clinic visit.

    What to do? My solution has been to obtain the telephone number and name of the supervisor immediately in the room and make a speaker phone call. When all parties are on the phone there can be no misinterpretation about the discussion and the expectations of return to work.

    Claiming that the boss is not following restrictions is not a reason to put the worker entirely off work. Often the employee will cite that it is uncomfortable to bring up the issue of work activity with the employer or in front of other workers.

    In this situation I do the following:

    “Mr. Smith, it sounds like you find yourself in an uncomfortable position with raising the issues of following work recommendations. I completely understand. The next time this issue arises I would like you to give my card to your supervisor and ask them to call me immediately. Please inform your supervisor that we have formulated these instructions to prevent your condition from worsening, and as such, please have your boss call me prior to performing the activities. If any problems remain I would encourage your employer to actually come into the clinic so we can come up with a plan that works for everyone”.

  • The Process of Chart Review

    28 November 2012 / Chart Reviews, How To / Comments Off on The Process of Chart Review

    Very little is formally written about the process of chart review. The style varies greatly between medical providers, and we had a very hard time finding anything describing this important event in the medical legal report.

    Chart review for the most part is regarded with dread and dislike. We want the chart because it is important to see what has or has not been documented in the case. We want to know the work up, the interpretation of the work up, and an inside look at the case. On the other hand, we fear the chart. How much will there be? Who actually has the chart?

    When performing the actual medical legal visit, often only a part or a small part of the chart is available.

    The Fed Ex pouch that mocks us silently in the mail room. Menacing really.

    I think we all have this experience in common. The first encounter is always visual. How big is that box? Is it a bluff and only one half full? And what kind of creative packaging are we dealing with today?

    I truly believe that the packaging of the medical record chart gives special insight into the personality of the sender. Examples? I have received medical records in recycled grocery bags with duct tapes, Nike shoe boxes, once in a cereal box, and my favorite…a Jack Daniels carton. Fascinating! Unfortunately I am not creative enough to make this stuff up.

    Grasping the chart has a certain sense of intimacy. It is like grappling with the opponent up close. Even like a hand shake. It is here that consideration of the medical records becomes more personal. The weight. The weight quickly gives a sense of the gravity of the situation. "Hey, this is a lot heavier than it looks!" or "How could they possible pack this much mass into such a small space?"

    Personally, I am one of those that have to know right away. I am actually a bit unsettled until I look inside quickly. I would be unable to focus, or sleep, or eat with satisfaction unless I can see what the contents of the box contain. I always am therefore always compelled to open the box immediate. After all, this may represent four to seven hours of my life flashing in front of my eyes.

  • Recommendations for Chart Reviews

    19 October 2012 / Chart Reviews, How To / Comments Off on Recommendations for Chart Reviews

    • Purchase Writing and Defending Your IME Report, The Comprehensive Guide by Steven Babitsky, Esq, James J. Mangraviti, Jr., Esq, and J. Mark Melhorn, MD. SEAK, Inc.
    • Become an Adobe “Jedi Knight Master” if you work with electronic medical records.
    • Look for themes and trends in specific notes. Are they consistent?
    • What is missing in the chart if you were managing the case?
    • What is or is not present to confirm the working diagnosis of the report?
    • Be judicious with what you present in your chart review. Be easy on the reader’s eyes, and obvious with what is valuable.

    Fear no chart!

  • In Summary: A Well Prepared Chart Review

    11 October 2012 / Chart Reviews, How To / Comments Off on In Summary: A Well Prepared Chart Review

    A well prepared chart review will separate your report from all those before it.

    The reader will welcome a comprehensive, yet economical review of the documents, be they five, 50, or 5,000 pages.

    Your role is to organize and weigh value to the contents, while searching all documents you have been provided.

    These documents include the longest consultant note down to the incidental photo copied post it note. Look for subjective and objective trends that support your conclusion.

    Finally, a link needs to be made that will bring together your first hand information and check it with the experience of other examiners.

    Chart review is a practiced skill. Develop a repeated method when approaching the chart and you will be less likely to miss valuable information. Your report will be stronger.

  • Summarize or Plagiarize a Medical Chart Review?

    05 October 2012 / Chart Reviews, How To / Comments Off on Summarize or Plagiarize a Medical Chart Review?

    This is an interesting question.

    Some reviewers will summarize chart notes. It will generalize the nature of the visit, the contents of the findings, in the opinions of the doctors. I personally prefer taking the actual excerpts of the chart document notes and including them in the review section.

    I do this for the following reasons. First, I do not want my “opinion” to replace the chart information. I like the reader to read exactly what I have read, so there's no misunderstanding on what is presented in the chart.

    Second, I like to use quotation. Quotation is valuable to make a highlighted comment on a specific opinion are finding in the medical chart review.

    When using quotations, it is important however, not to take them out of context. Using quotations incorrectly may result in your report as being viewed as “biased” for one side or the other. If the employee or doctor makes a statement, that is critical or contradictory, I may consider that section of the chart as a quotation.

    Finally, when selecting direct text into the chart review, the use must be judicious. Remember, writing and editing is an active, if not aerobic, process. It requires thinking and editing.

    Read what you have selected. Does it add to the value of the report? Keep clear in your mind what is subjective and what is objective in the review being created.

  • Ancillary Medical Chart Notes

    27 September 2012 / Chart Reviews / Comments Off on Ancillary Medical Chart Notes

    Valuable information is often found in the “ancillary” chart.

    The ancillary chart are those notes generated by the medical assistants, the front desk, or a hand written note the employee may have dropped at the front desk.

    Physical therapy notes may be a “gold mine” of information, as the therapist often has longer periods of time for evaluation, and this can be reflected in review of the notes. Everything in the chart must be considered.

  • Medical Imaging & Diagnostic Tests in Chart Reviews

    17 September 2012 / Chart Reviews / Comments Off on Medical Imaging & Diagnostic Tests in Chart Reviews

    Medical imaging and diagnostic testing reports are of great interest. These reports are strictly objective.

    Check the reason for the ordering of the test. This is usually a one to two sentence statement. Check any diagnostic imaging prior that is used for comparison in the conclusions. Again, do the findings support the diagnoses? Has the imaging ruled in or out any diagnoses, you may have in your mind as you read the record?

    Remember, as you review medical imaging and diagnostic testing reports, are there any missing tests that would be critical for you to determine a diagnosis?

    If you're reviewing, diagnostic tests, such as laboratory data, be sure to include normal range values. The reader may not know the normal ranges, or normal may vary from lab to lab.

    I review laboratory results as "normal", "abnormal elevated", "abnormal low”, and "borderline high or low". If the laboratory value is going to play a critical role in my opinion, I will of course dictate the exact numeric value.

    Search the chart for specific labs. For example, the hemoglobin A1c in diabetics when the case involves a nerve condition, i.e.carpal tunnel syndrome.

    If such information is lacking in the medical record, be sure to comment on it and its significance in your discussion. The same is true with diagnostic tissue pathology. Example, if you're a dermatologist, confirmatory biopsies are critical in formulating a working diagnosis.

    If a diagnosis needs to be made by tissue and is not included in the chart documents, be sure this is highlighted in your discussion.

  • Medical Imaging & Diagnostic Tests

    27 August 2012 / Chart Reviews / Comments Off on Medical Imaging & Diagnostic Tests

    Medical imaging and diagnostic testing reports are of great interest. These reports are strictly objective.

    Check the reason for the ordering of the test. This is usually a one to two sentence statement.

    Check any diagnostic imaging prior that is used for comparison in the conclusions. Again, do the findings support the diagnoses? Has the imaging ruled in or out any diagnoses, you may have in your mind as you read the record?

    Remember, as you review medical imaging and diagnostic testing reports, are there any missing tests that would be critical for you to determine a diagnosis? If you're reviewing, diagnostic tests, such as laboratory data, be sure to include normal range values.

    The reader may not know the normal ranges, or normal may vary from lab to lab. I review laboratory results as "normal", "abnormal elevated", "abnormal low”, and "borderline high or low". If the laboratory value is going to play a critical role in my opinion, I will of course dictate the exact numeric value.

    Search the chart for specific labs. For example, the hemoglobin A1c in diabetics when the case involves a nerve condition, i.e.carpal tunnel syndrome. If such information is lacking in the medical record, be sure to comment on it and its significance in your discussion.

    The same is true with diagnostic tissue pathology. Example, if you're a dermatologist, confirmatory biopsies are critical in formulating a working diagnosis. If a diagnosis needs to be made by tissue and is not included in the chart documents, be sure this is highlighted in your discussion.

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