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 favoriteā€¦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.

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