Medical and Life Care Consulting Medical Chart Reviews

Medical Chart Reviews and Chronologies: Seven Best Practices and Why They’re Important

Documentary evidence is a critical component of all litigious matters. Thinking specifically about retrospective chart reviews, also known as a medical record review, a thorough understanding of the information within medical records can make or break a case. In this month’s INSIGHTS article, we explore medical chart reviews and chronologies and share seven best practices for attorneys and paralegals when reviewing medical records, interpreting the information, and when to engage a medical professional for expert review and analysis.

What is a medical chart review, and what is a chronology?

Medical records include various components and documentation of patient history, clinical findings, diagnostic test results, preoperative care, operation notes, post-operative care, and daily notes of a patient’s progress and medications after an injury or illness.[i] “The medical record frequently is the most important document available in defending against or preventing legal actions, including but not limited to personal injury suits, criminal cases, workers’ compensation actions, disability determinations, and claims of negligent or improper healthcare (medical malpractice), and is generally admissible at a trial.”[ii] A medical record chronology organizes medical records, treatment history, and medication history from the injury or illness date to the present.

When should a medical chart review and chronology be completed?

A medical chart review and chronology is completed either before or after a lawsuit is initiated. Before filing a case,  a medical chart review and chronology is a great resource to reveal the story, gain a deeper understanding of the injury or illness, and determine whether liability is attributed to the opposing party. A medical chart review might also be completed after a lawsuit is filed by either the plaintiff or the defense. The complexities and long-term implications of an injury or illness, the necessary treatment, and the attorney’s experience generally inform whether a review and chronology is completed before or after initiating legal action.

To get the most from a medical chart review and chronology, we share seven best practices for reviewing and understanding medical records and the stories they tell.

  1. Understand the information you’re looking for and how it gets into the chart

A foundational understanding of who adds information to a medical record and how that information is added is paramount to completing a thorough medical chart review. Many health care providers can add information to an individual’s medical chart, including the medical transport team, physicians, nurses, laboratory technicians, physical therapists, and any other health care professional providing care. Consider an automobile accident with 12 months of post-injury treatment; at the very least, records should be reviewed from the accident’s scene or initiation of injury to the present time.  In this instance, records include those of the EMT team that assist the scene, emergency room records, in-patient acute hospital records, rehabilitation hospital records, and outpatient care and physician visit records. And each encounter with a professional may include the chief complaint, physical exam, history of present illness, an assessment and plan, lab or radiological orders, prescriptions, progress notes, and test results.

 

It is also essential to understand how the information gets into the record – is it dictated and transcribed, or handwritten, as the method used for charting can affect the accuracy of the information. According to Air Medical Journal, “…the process of dictation and transcription has been shown to introduce more inaccuracies into the medical record, such as in recording childhood immunizations.”[iii] Electronic health records add yet another layer of complexity and may be confusing for the untrained eye to review and understand.

  1. Ask Questions

The more questions you ask, the more information to factor into your case, including pre-existing injuries and illnesses, medications, and prior and current treatments. When interviewing your client, ask open-ended questions to learn as much as you can about the patient’s health history. The goal is to uncover any other illnesses or conditions and when they might have begun, medications they are presently taking or may have taken in the past, or any information which may factor into how the individual is healing.

References: 

[i] Medical records and issues in negligence

[ii] Legal Issues in the Medical Record | Effective Documentation for Physical Therapy Professionals

[iii] Performing chart review studies

Planning for the future? Determine the type of vocational services your case needs

At Medical and Life Care Consulting, our work within medico-legal claims and life care planning often uncovers the need for additional resources such as the vocational consultant to provide an opinion on an individual’s ability to work and earn money. In this issue of INSIGHT, we’ve partnered with CRC Services’ vocational consultants, to explore the vocational rehabilitation field, the role of a vocational consultant, and examine how and when the expertise of the vocational consultant may intertwine within a case. In addition to this article, we invite you to learn more about vocational rehabilitation consulting and expert witness services in our upcoming webinar “The Rehabilitation Continuum: Working with a vocational consultant within your medico-legal case,” click here to learn more.

More than 10% of U.S. adults report a disability; slightly more than 20 million Americans between ages 18 and 64 report having a disability[i]. In 2004, the World Health Organization published that unintentional injuries were responsible for over 3.9 million deaths and over 138 million disability-adjusted life-years.[ii] Disability-adjusted life years (DALYs) represent the total number of years lost to illness, disability, or premature death within a given population.[iii] When an individual is significantly injured, their lives are altered, and their road to recovery often extends beyond physiological aspects of healing and includes recovery and rehabilitation of how the individual works. The practice of vocational rehabilitation uncovers their abilities and helps develop a roadmap for returning to the workforce.

What is vocational rehabilitation?

According to the National Rehabilitation Information Center, vocational rehabilitation is made up of a series of services that are designed to facilitate the entrance into or a return to work for people with disabilities or by people who have recently acquired an injury or disability.

Medical and Life Care Consulting

Some of these services include vocational assessment and evaluation.  Following the vocational interview and administration of vocational testing, vocational consultants are uniquely qualified to create suitable vocational rehabilitation plans. Plans typically encompass suitable post-injury job matches, identification of short-term and/or long-term retraining programs and research of the programs to include cost, duration and accommodations needed, and the coordination and needs of public and/or private vocational rehabilitation professionals.  Vocational consultants also provide job seeking skills training (i.e., career counseling, resume and cover letter development, interviewing techniques, proper application completion, education and tips for proper disability disclosure), labor market research, employer and job development, analysis of any on-the-job accommodations and ancillary support services (e.g., job coach, transportation, nurse’s aide, among others).  Vocational consultants can work with individuals to provide various levels of exposure to the world of work such as informational interviews, job shadowing experiences, work readiness evaluations, internship/volunteer experiences, and paid employment.

Working with a vocational consultant within a medico-legal case

In a medico-legal case, there are instances where a vocational consultant and expert are required to provide an opinion on an individual’s ability to work and earn money. Through their expertise and professional services, clients become educated on the art and science of the private vocational rehabilitation field, vocational methodologies, nomenclature, and common treatises used. The services of the vocational consulting and expert may also include records review and preliminary vocational analysis, in-person vocational assessments including a vocational interview and administration of standardized testing (intelligence, memory & concentration, achievement, aptitude et al.), transferable skills analysis, pre-post injury analysis, and labor market research to determine the availability of suitable employment and associated wages; if applicable.  Vocational Consultants also assist attorneys with strategizing their cases by peer-reviewing the opposing vocational expert’s reports and/or opinions and discussing areas in which the attorney can develop the case (e.g., post-injury academic performance, post-injury work experience, among others). As a vocational consultant, or expert witness, the vocational rehabilitation consultant will address the plaintiff’s level of employability and wage-earning capacity pre- and post-accident. In catastrophic cases, future vocational rehabilitation needs may be addressed and as a component of a life care plan.

When the work of the Nurse Life Care Planner and the Vocational Expert Intertwine

Oftentimes, in catastrophic cases involving young adults, future work may be possible with significant supports. As a case example, imagine an 18-year-old injured in a motor vehicle accident and becoming a paraplegic. The individual received above-average grades in high school and was college-bound before the accident occurred. Cognitive testing demonstrated they possessed above average intelligence and college-level aptitudes (e.g., reading, spelling, math). In this case, in addition to providing an opinion with regard to the plaintiff’s pre-post injury level of employability and wage-earning capacity…

The content for this article was developed and published in coordination with CRC Services, LLC, and provided solely for informational and educational purposes. This article was not released as a means of endorsement or advertisement for either Medical and Life Care Consulting or CRC Services, LLC or constitute a formal partnership between each organization.

What exactly is the practice of Nurse Life Care Planning and a Life Care Plan?

The formal practice of Nurse Life Care Planning, which is approximately twenty-years-old, is often misunderstood by industry partners including attorneys, fiduciaries, and even professionals within rehabilitation, insurance, and health care management. For individuals suffering from a catastrophic injury or illness, a life care plan informs private fiduciaries, legal professionals and case managers of the long-term resources required for the individual’s long-term care, health, and wellness.

A life care plan is typically developed by a nurse life care planner whose primary role is to develop a client-specific lifetime plan of care utilizing the nursing process. The plan contains an organized, comprehensive, and evidence-based approach that estimates current and future healthcare needs. A life care plan also includes the associated costs and frequencies of items and services needed for care and can be applied in various sectors including private, medical-legal and case management by serving as a valuable guide.

This white paper provides an overview of nurse life care planning, as a practice, the customary components of a life care plan, and aims to articulate the vital need for a life care plan when managing a medico-legal claim of an individual who’s been catastrophically injured or ill. Any information, sample tables, or opinions within this whitepaper are purely the opinions of Medical and Life Care Consulting Services, Inc. and should not be used as legal advice, counsel, or testimony of any nature.

Download the complete white paper today!

Nurse Life Care Planning

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Understanding and preparing an accurate Pediatric Life Care Plan

In 2018, nearly 3.8 million babies were born within the United States. Most of these infants started their lives with no issues at birth and began achieving typical developmental milestones, yet, there were those whose lives were forever impacted by a birth injury. In the United States, it is estimated that nearly 7 birth traumas occur per 1000 live births, with an incidence rate of approximately 1 in 9,714[i]. Nearly one half are potentially avoidable with proper recognition and anticipation of obstetric risk factors. [ii]

Birth injuries can range from minor, temporary, and self-healing to permanent, catastrophic, and having a lasting impact on the morbidity or mortality of the child. Birth injuries are typically divided into two categories, those resulting from hypoxia and ischemia (a lack of or shortage of oxygen) or injuries resulting from mechanical forces during the process of labor and delivery.[iii]

A birth injury likely to result in litigation is hypoxic-ischemic encephalopathy (HIE). HIE is the most common birth injury claim, generally alleging that intrapartum asphyxia led to long-term neurologic sequelae, including cerebral palsy and/or developmental delay.[iv]

Trying to understand the child’s life, determine what their day is like, how they perform in the school system, and how they interact with their families is a key component of evaluation and outlining resources, treatments, and supports needed for the child’s care continuum.

How will the injury impact life expectancy? What will their life look like after K-12 schooling? While schools are mandated to provide the appropriate environment and services needed to facilitate the child’s learning and development – this only continues until the child is twenty-two years old.  Planning and preparation of the child’s care and supports must be made well in advance and outline the child’s care once they are no longer in the school system. Proper planning must also align and support the family’s goals and decisions regarding their child.

In this issue of Insights, we share a sample of a Life Care Plan for a child diagnosed with Hypertonia and Global Development Delay. Hypertonia is a condition in which there is too much muscle tone so that arms or legs, for example, are stiff and difficult to move[v]. The long-term prognosis of a child diagnosed with Hypertonia is dependent on the severity and its cause. Global developmental delay is defined as a child having delays in two or more developmental milestones. At the time of the case, the child was seven years old and is expected to live into their eighties. Delays may include walking, talking, movement skills, and social-emotional development milestones and the delay is continued for at least six months[vi].  Understanding the long-term care and needs of the child requires a complete understanding of the child, the supports provided by family and rehabilitation professionals, and the care needed for the remainder of the child’s life.

When a Nurse Life Care Planner assesses the child, they are also assessing the family functions. Determining the families understanding of the injury, the child’s prognosis for recovery, family dynamics, and understanding the capacity and limits of the primary caregiver. Is the family bilingual? Who works outside of the home and how does that impact care? Is the family a larger extended family with grandparents living in the home, or is it a single parent managing one child or more?  It is also important to take into consideration the living environment when determining the needs of the child.

Pediatric Life Care Plan

Treatment is treatment, whether in a little body or a big body, what’s key is understanding the long-term effects of the diagnosis and treatment on the child’s life. Going to school and being included in the day to day routines and activities of being a child, a son, or a daughter, are important to consider for maximum quality of life.  Reconstructing a day-in-the-life experience is very important in cases with children.

Understanding and planning for the long-term needs of a child who’s experienced a significant birth injury with lasting implications require a deep understanding of their diagnosis, the unique factors surrounding their care, and expertise in the long-term prognosis.

Wondering what you could expect in a Pediatric Life Care Plan? Access the Pediatric Life Care Plan snapshot below. Please keep in mind that the snapshot you access is only a small portion of an actual Life Care Plan.

If you’re an attorney or legal professional managing a birth injury case or any case involving a child, be sure you’re working with a team of professionals who have experience and expertise in the diagnosis, prognosis, and the aligning care needs.

References:

[i] Right Diagnosis from Healthgrades: Statistics about Birth Injury

[ii] Medscape: Birth Traumas

[iii] Clinic in Perinatology: Management of Birth Injuries

[iv] Seminars in Fetal and Neonatal Medicine: Medico-legal implications of hypoxic-ischemic birth injury: https://doi.org/10.1016/j.siny.2014.08.005

[v] National Institute of Neurological Disorders and Stroke: Hypertonia Information Page

[vi] Cerebral Palsy Alliance: Global Development Delay

3 Things attorneys may not know about Medicare Set-Aside allocations

Cynthia Bourbeau, RN, CRRN, CCM, CNLCP®
Founder & President – Medical and Life Care Consulting Services, Inc.

The Centers for Medicare Services defines Medicare Set-Aside (MSA) allocations as financial agreements that allocate a portion of a workers’ compensation, medical malpractice or personal liability settlement to pay for future medical services related to the injury, illness or disease. These funds must be depleted before Medicare will pay for related treatment.

We work with attorneys to evaluate a person’s future medical needs and recommend an amount that should be set aside for future medical care. Once the government approves this amount, the administrator of the MSA fund uses the funds to pay for medical care related to the plaintiff’s injury. For example, if there is a settlement case for $6 million, and $2 million of that was approved for medical and care costs, that amount is put aside for future medical costs.

1. Medicare Set-Aside allocations not required in all states…yet

Medicare requires Medicare Set-Aside allocations in many states. The conditions under which an MSA is required vary by state, and attorneys need to be prepared. While an MSA is not required in all states, the federal government requires that Medicare’s interests are considered in all settlements for those people who are Medicare beneficiaries or likely to become a beneficiary in next 30 months.

MSAs have been used for years in workers’ compensation cases, and the government has extensive reporting and monitoring rules in place. MSA law is complicated and constantly changing, reinforcing the need for an experienced life care planner.

2. Who is responsible to ensure an MSA is completed?

When MSA allocations are mandated, it is the attorney who is responsible to ensure one is completed and the money is put aside. Medicare can collect against insurance carriers, the client, their legal counsel and their advisors—any counsel involved in a settlement—because of workers’ compensation, liability or no-fault settlements when the financial interests of Medicare are not protected with an MSA.

3. We will improve your MSA claims, settlement outcomes and trust arrangements

Our life care plans present concise standards of practice, data analysis, research, clear chronologies and evidence-based plans for current and future costs to maximize wellness throughout the patient’s lifetime.

We work with attorneys across the country to develop life care plans and MSAs, complete the Medicare paperwork, and make the necessary notifications. We offer best practices with a clinical approach for formulating MSA allocations to remain compliant with Medicare.

If you are an attorney specializing in medical malpractice, workers’ compensation or liability claims, contact us today to learn how we can help you plan for your client’s future.