The various processes involved in medical chart review have to be carefully executed to ensure completeness and accuracy which are vital to determining the validity of a legal case

1. http://www.mosmedicalrecordreview.com Phone: (800) 670 2809 1
What are the Processes involved in Medical Chart
Review?
Physicians and attorneys representing insurance firms have to review
medical records so as to make available accurate information for the
verification and reimbursement of insurance claims. The various processes
involved in medical chart review have to be
meticulously executed to ensure completeness
and accuracy which are vital to determining
the validity of a case. Medical record review
companies in the United States are specialists
in the chart review procedure and offer
detailed and timely support services to meet
the needs of the medico-legal industry.
The Medical Chart Review Procedure
Medical charting involves processes such as medical chart audit,
organization of the chart chronologically and by category, checking for
missing information, developing an analysis and summary of the chart, and a
timeline of events.
The reviewer makes a check list and conducts the medical chart audit to
ensure that the following information is available and complete:
• Patient demographic insurance information sheet: this would include
name, social security number, birth date, spouse's name, address,
phone numbers, insurance information, and so on

2. http://www.mosmedicalrecordreview.com Phone: (800) 670 2809 2
• Consent to treatment: consent given by the competent adult for
treatment for him/herself, especially surgery
• Emergency Department record: this should feature time and means of
patient arrival, diagnosis and other conclusions at the end of
emergency room treatment, whether the patient was sent home or
admitted, and so on
• Order and entry forms for laboratory, special testing, and imaging:
physician orders for lab and radiology tests, X-rays and scans
• General medical orders by departments: physicians’ and specialists’
orders on patient treatment
• History and physical examination report: history of treatment and
medication; if the case relates to a specific incident, only the history
relevant to that incident is necessary. The history and physical exam
reports help to determine the appropriateness of treatment
• Consults for specialized care: specialist medical records of the patient
• Progress notes: physician and nursing notes provide an evaluation of
the patient and a timeline of treatment and care – right from the time
of admission to discharge
• Medication records: the type of medication, time, dosage and
administration are examined as all this affects treatment
After checking to ensure that all this information is available, the next step
in medical chart review is to arrange the information according to category
and to develop chronologies and summaries. This involves:
• Taking the chart apart

3. http://www.mosmedicalrecordreview.com Phone: (800) 670 2809 3
• Grouping the chart into separate segments such as progress notes,
radiology notes, physicians’ orders, nursing progress notes, and so on
• Arranging these segments in chronological order
• Clubbing all the ordered pages under one group
• Numbering the pages
• Making copies of the entire medical record
The organization of the medical chart helps the reviewer to identify
important events and create a summary and timeline.
Expert Medical Chart Review Support Services for the
Medico-legal Industry
Medical records and charts which are incomplete, poorly maintained,
incomplete, inaccurate, and illegible can result in mismanagement of claims.
Physicians or attorneys who need to perform medical chart review or
medical record review would benefit greatly and save time and money by
relying an experienced service provider for support. Established outsourcing
companies are equipped with a team of experts knowledgeable about the
processes involved in medical chart review and can offer professional
support services to ensure accurate and error-free results. Reliable medical
record review companies offer competitively priced services in customized
turnaround time.

4. http://www.mosmedicalrecordreview.com Phone: (800) 670 2809 4
CONTACT MOS MEDICAL REVIEWS