Accuracy is vital in legal and medical documentation. Medical records should clearly reflect the evaluation and treatment of the patient and be consistent with the right levels of care.

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Importance of Accurate Documentation
in Personal Injury Cases
Accuracy is vital in legal and medical documentation.
Medical records should clearly reflect the evaluation and
treatment of the patient and be consistent with the right
levels of care.
Accuracy and attention to detail is paramount in any type of
documentation, especially with regard to legal and medical
documentation. The medical records
of a patient should clearly reflect the
evaluation and treatment of the
patient and must be consistent with
the appropriate levels of care. Many
healthcare providers do not seem to
attach the due importance to
accuracy and detail in their clinical
notes. It is important to understand
that clinical documentation serves many purposes such as
the following:
• To ensure the appropriate level of care to the patient
• To offer protection in case there is a medical
malpractice or personal injury litigation
• To improve communication with other providers and
healthcare professionals
• To standardize clinical documentation for research
purposes
• To obtain the correct reimbursement from payers
http://www.mosmedicalrecordreview.com/ 1-800-670-2809

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Loopholes in Documentation
Let us consider the chiropractic profession. A professional
chiropractor would ensure that the initial entry in a patient
record would include a detailed case history with clear
documentation as regards past history, examination of
symptoms, family history, surgeries undergone, previous
and current medication and such important details. The
medical records should be comprehensive and highlight the
care, treatment and interaction with the patient.
Many chiropractors fail to document active care which is
very important with regard to the treatment provided to the
patient. It is proved by recent studies that chiropractic
works best when it is combined with rehabilitation
exercises. Active care must be started within the initial 4 –
6 weeks of treatment, and this documentation is required by
insurers.
In personal injury cases, it is important to ensure that the
patient has a definitive treatment plan outlining the
duration, expected results and the treatment objectives. It is
important to be highly specific about the exercises that are
recommended and being performed by the patient. This is
important from the point of view of determining how many
times the patient has performed a specific exercise, and
decide whether it is time for him/her to move to the next
step in the treatment protocol. Active care and
rehabilitation exercises are given thrice the value of passive
care such as electric muscle stimulation, traction or
ultrasound.
Points to Note with Regard to Documentation
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• Clear-cut classification of treatments as “prolonged”
and “intensive.”
• Note down home exercise recommendations
• Write down all verbal instructions given to a patient
• Bed rest is considered active treatment since it
requires the active participation of the patient.
Therefore it is important to note this down in the
patient record.
Documenting rehab can be really challenging, nevertheless
it is something that has to be done with extreme care and
caution. It should be done in such a way that it is clear
enough to the attorney or adjuster and facilitate speedy
processing.
Medical records are an important factor with regard to
personal injury cases. Attorneys handling PI litigation will
need to review the relevant medical records and obtain a
concise medical history and summary to understand the
various aspects of a case. A detailed medical chronology
will help them to understand the sequence of medical
encounters. A medical record review company can assist
attorneys with complete medical review services. Reliable
services will help attorneys save considerable time, effort
and expenses while also ensuring that they prepare the case
well and go on to win it.
Posted by MOS Medical Record Review Company
http://www.mosmedicalrecordreview.com/
http://www.mosmedicalrecordreview.com/ 1-800-670-2809