Tips for Organizing Medical Records
As mundane as the task may sound, properly organized medical records saves time, money, and effort, and helps to avoid confusion. I highly recommend doing this, especially if you anticipate sending records to physician experts. Organized records will enable an expert to review the records faster and help them find key information - sometimes even a critical detail they might otherwise have missed. Organized medical records can also make the attorney's job easier down the line, for such things as depositions and trials.
In this section I will explain my method of organizing records. I've organized thousands of records for my attorney-clients and it has benefited all involved. I'm aware that seasoned attorneys know will already be aware of much of this information. Still, they (or their legal secretaries) may find some helpful tidbits.
I would also point out that PDF's can be made from the organized records and I can easily bookmark/tab them, to make them user-friendly. Using PDF's can save money and in some ways be preferable to hard copies. [See my topic on PDF's.]
Preparation
Before starting, there are initial considerations - some fairly obvious, but I'll mention them just the same. 1) Make sure you have a properly executed medical record authorization and permission from your client to have the records reviewed. 2) Ensure that the records are as complete as needed for your purposes. 3) Use legible copies, and without any client notes written on them. 4) For lengthy hospitalization records, use medical tabs so you can further divide each hospitalization into sections (progress note, labs, etc.). 5) You might want to postpone Bates stamping, until the records are as complete as needed and properly organized. This can save confusion later, if each record has multiple Bates stamp numbers. 6) Consider having the records professionally organized by a nurse consultant — rather than your legal secretary — as the task can be a bit tricky. For instance, if one page has 3 different dates on it — or sometimes even the wrong date — how does one determine its correct chronological order?
Organizing
Firstly, there are two basic types of records: billing and medical records. The physician expert will probably not need the billing records, but they can be helpful for the nurse consultant for such things as making sure you're not missing any visits or tests from the medical records. At any rate, I suggest keeping each providers' billing and medical separate.
Medical providers generally fall into 3 different categories: 1) Individual providers (doctors, physical therapy, etc.); 2) Outpatient services (ER visits, outpatient tests, etc); and 3) Hospital admissions. Typically, each provider will have a number tab with an index at the front of the binder.
Individual providers
My general rule of thumb for organizing doctors' records is:
Provider > Type of document > Chronological (or reverse chronological) order
I would put the actual office visits up front and organize those visits in either chronological or reverse chronological order. After the office visit section, I would then put other patient information (patient questionnaires, health history, telephone calls, medication lists, etc. After this you could have a miscellaneous section, which you may or might want to further organize.
You never know what additional documents you might get from the doctor, but actually the more the better. [You might, for instance, find an X-ray report or another doctor's records you weren't aware of.] Be mindful that you don't confuse the doctor's office visit records with those he received from another doctor.
Outpatient services
My general rule of thumb for Outpatient service providers' records is similar to the doctors:
Provider > Type of document > Chronological (or reverse chronological) order
Another rule of thumb is to put the important part(s) up front. For instance, an outpatient X-ray may have 15 pages of relatively superfluous pages. In this case, I would have the face sheet up front, immediately followed by the X-ray report. That way, someone doesn't have to hunt around for it.
If you have hospital outpatient visits, in addition to admissions from the same hospital, I would suggest keeping them separate, so they don't get lost in the more voluminous hospitalization records.
Hospital admissions
My general rule of thumb for organizing hospital admissions is:
Provider > Date of admission > Type of document > Chronological order.
Organizing hospital records can be the most daunting, especially for the inexperienced. If you're lucky, the records you receive from a hospital will already be somewhat organized similar to the above, although some additional tweaking is usually helpful.
Especially for lengthy admissions, I would use medical tabs to separate the document types for each admission. General document types include:
Admit discharge information (face sheet, discharge summary, history and physical)
Physician Progress notes
Consults (initial consult reports from specialists, typically dictated)
Orders
Operative (Operative report, Anesthesia, perioperative nursing)
Labs (CBC, Chemistry, Microbiology, Blood bank documents, arterial blood gases)
Radiology (X-rays, CT's, MRI's, etc)
EKG (12 lead EKG, monitor strips, echocardiogram)
Graphics (vital signs, intake & output)
Medications (MAR = medication administration record)
Nursing (subdivided into type of nursing document, such as ICU, Floor, Dialysis, etc,)
Ancillary services (Physical and Occupational Therapy, Speech Therapy, Social work)
Consents
When possible, I recommend using chronological order for each section, as opposed to reverse chronological. Although doctors are used to seeing reverse chronological, they can just as easily follow regular chronological, and it will make things easier for others, such as the attorney. As noted above, each general document type may have sub-types. Sometimes it may be better to also separate the subtypes, and then put each sub-type in chronological order.
Here are some additional tidbits you may find helpful. 1) If there are voluminous records from a hospitalization, put the nurses notes and medications in a separate binder. Most of the records will be nurses notes and medications, and your expert will appreciate not having to thumb through all of them to access other parts of the chart. 2) Again, put the important sections up front, similar to how I've listed them above. 3) Be mindful of getting the date right. Deciphering the correct chronological date can be tricky. Also be aware that nursing documentation and medications may overlap from one day to the next, i.e. a shift from 11 pm to 7 am. 4) If the hospitalization includes a stay in the ICU, I would keep the ICU nursing documentation separate from the floor nursing. Also the ICU forms will include things like vital signs and I&O, which should be kept with the ICU nursing, as opposed to the graphics section. 5) Print-outs of electronic records can take many forms and sometimes it's not pretty. Usually you're better off not trying to reorganize what the computer has already has done, and especially if there are already computer-generated numbers for these sections. For instance, often you'll see electronic nurses notes and lab reports put in a certain order by the computer. Sometimes there just isn't a sensible way to reorder them, even if you wanted to. This may also be true for some computerized physician notes, such as when there is no logical way to chronologically reorder them, and/or they include previous labs and visits.
In closing
Organization of medical records is an entirely different beast than organization of other legal records. The purpose of my little treatise here, is to give the attorney (and legal secretary) an overview of what's involved and offer some pointers. I would again stress that, especially if there are voluminous records and you anticipate litigation, you'll save yourself a lot of money and grief by having your medical records properly organized by a nurse consultant, such as myself.