LNCtips.com: Is the Chart Complete?
If you've ever worked at a hospital, you know that the Medical Records department reviews each patient's chart after discharge to see if the chart is complete. Most attorneys don't hire medical records technicians so lawyers often rely on legal nurse consultants for this function. Sometimes it's easy to tell when there are missing pages in the medical records. Sometimes charts are incomplete in more subtle ways. And sometimes attorneys send LNCs incomplete charts on purpose.
Let's look at the obvious ways to determine if a chart is incomplete. One of the most common reasons for an incomplete chart occurs because the provider didn't copy both sides of a page. Another common occurrence is missing pages within a sequence of numbered pages. For example, nursing flow sheets are often numbered as page one of eight, page two of eight, etc. Of the charts that I review, at least one-third are missing some of the pages this way.
Other missing records aren't quite as obvious, unless you know what to look for. For example, every physician office obtains a copy of the patient's (or parent's or guardian's) photo identification and insurance card. Similarly, prescriptions, prescription refill requests, and authorizations for expensive tests (CTs, MRIs, genetic testing, etc.) should be a part of almost every office chart. If your set of records doesn't have this information, the records are most likely incomplete. I'm finding that as physician offices transition to electronic medical records due to HITECH, more offices are sending me incomplete charts.
Another way to tell if a chart, particularly a hospital chart, is incomplete is to compare physician orders and progress notes to other documentation in the chart. For example, if a physician orders a blood culture, the nursing staff documents that they obtained the blood culture, but there's no blood culture report in the chart, the chart is incomplete.
Also, check to see if the chart contains final radiograph reports. Non-radiologists sometimes read preliminary reports. For example, an Emergency Department physician might read an x-ray and generate a handwritten, preliminary report. Radiologists always produce final reports. The legal nurse consultant needs to compare the final report to the preliminary report to determine if there are any discrepancies between the two.
You might also receive some charts that are supposed to be incomplete. For example, some attorneys order abstracts. An abstract of a medical record is a condensed version of the record. It typically contains the history and physical, consultations, physician orders, progress notes, x-rays, labs, operative/procedure records and the discharge summary. However, an abstract can contain any records that the attorney selects. Another example of a deliberately incomplete chart occurs when the attorney or law office staff handpicks pages of the medical record. In the case of an abstract, the attorney orders an incomplete chart from the provider. In the case of a handpicked chart, the attorney has the entire chart but only send selected records to the legal nurse consultant. In both cases, cost is usually the reason for the incomplete chart. A smaller, incomplete chart means less cost to obtain the record or less cost to have it reviewed.
What do you do when you determine that a chart is incomplete? Let the attorney know what's missing and whether you believe that the missing sections are important to your review. The attorney will decide whether to obtain the missing parts of the chart.