Clinical Office Visits and Medical Chart Reviews

06 August 2012 / Chart Reviews / Comments Off on Clinical Office Visits and Medical Chart Reviews

I will search for pain scale reports, compliance with medications, listed medications, and essential physical exam findings pertinent to injured body part.

Will try to find the doctor’s thought process and reasoning for the management of the claim. I will look for response to treatment, and any indication as evidence in “objective” improvement.

Objective improvement has both “soft” and “hard” findings.

The soft side is the report of improvement in the activities of daily living, or the ability to tolerate symptoms better. Hard objective improvement is the exam measurements. Is range of motion, improving, stable, or deteriorating?

I collect all of these findings for my chart entries.

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