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5 Areas of a Chart to Review in Every Medical Record Analysis

By: Carol Hayes RN, BSN, CLNC
Tel: 217-491-5562
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In every medical related case there are areas of the medical record that should be evaluated regardless of the type case or the surrounding circumstances. These areas of the record are important because they can contain key pieces of information about what did or did not occur during the care of that particular patient. A thorough medical record review should be done for any case involving medical issues, whether it is for the plaintiff or the defense.

  1. Physician�s Orders: It is important to review the orders written by the physician to determine if those orders were carried out by the nurses and other appropriate staff. It should also be noted if these orders were taken care of in a timely manner and if they are relevant to the patient�s diagnosis.
  2. Progress Notes: The physician and nurse�s progress notes are significant because they create a timeline about the patient�s condition from admission to discharge. They contain valuable information on the response to treatment and care. Progress notes give a perspective on the physician�s and the nurse�s evaluation of the patient.
  3. Lab Reports: Interpretation of the lab results can provide clues to the diagnosis of the patient. Abnormal results may also point to a condition that may have been undiagnosed by the physician.
  4. History and Physical (H&P): The H&P is usually done by the physician after the first evaluation of the patient. It gives information about what signs and symptoms the physician noted, and the initial impression and diagnosis. H&Ps are important in evaluating the physician�s workup and determining if the prescribed treatment was appropriate. A patient�s previous medical history is a valuable tool for alerting the physician about what needs to be done or avoided in the treatment plan.
  5. Medication Record: All medications given by the nurses are recorded in the medical record. The type of medication, time, route of administration and dosage are all important pieces of information that can signal an error or delay in treatment. It is essential to compare the medications given with the physician�s orders.

Because the medical record is such a critical source of information in any medical related case, the review should be done by someone who is experienced and familiar with the components and language of the record. Nurses are experts in medical record review. They are detail oriented and can identify pertinent areas of the record that are often missed by others. Nurses are the ideal professional for a complete and efficient analysis.

Carol Hayes, has 22 years of Nursing experience with 19 years specializing in the Operating Room. She has vast experience in many areas of surgical nursing. Carol can provide expert testimony for OR nursing issues.

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