LNCtips.com: Medical Records General Tips
Many medical records are now in electronic format and do not need to be organized. However, these general tips are helpful for non-electronic medical records.
Before You Organize
If you are an independent LNC, make sure that medical record organization is part of your contract or letter of understanding. Do not assume that your client wants the records to be organized or that your client will pay you for that service.
If you are an expert, you will not be expected to organize records. It is not unreasonable to request that your initial set of records be sent to you in tabbed binders.
If you work in a law firm, your firm may preserve one copy of the records in their original order by either scanning them into a computer network or by keeping them in their hard copy order. Subsequent hard copies (called working copies) can be made, placed in desired order, and marked up as desired.
Bates Stamped Records
Bates stamping is a process in which a unique number is assigned to each page of the medical records. This allows everyone using the records to quickly locate specific documents by the unique number.
Bates stamping can be done manually or electronically. If you work as an in-house LNC and plan to Bates stamp your records, it's usually better to do so after the records are organized. If you receive records that have already been Bates stamped, it is better to leave the records in that order, even if the records are not organized in your customary order. Reorganizing Bates stamped documents changes the order of the records and makes it difficult to locate their unique numbers.
General Tips for Organizing Medical Records
Legal nurse consultants organize paper medical records for two reasons. First, organization provides a consistent format that is easy to comprehend. Second, it helps LNCs to determine if the records are accurate and complete. Once the records are organized, they are usually tabbed by categories and stored in 3-ring binders. While electronic medical records can be organized, it involves a different process. The following tips pertain to paper medical records.
Medical records generally arrive in category order (such as progress notes, nursing notes, medications, etc.) and in reverse chronological order (most recent information first). Some attorneys prefer to keep the records in the exact order in which they were received from the provider. However, many attorneys prefer that each category be put into chronological order (the most current date and time last) because records are much easier to read when they are in date and time order. The order in which you arrange the records is not set in stone. The book, Principles and Practices has several examples of chart order or you can use the examples listed in the Hospital, Nursing Home and Home Health web pages of this site.
Scanned records can be printed at 90% of their original size for your working copy. This size is still large enough to easily view the records but the smaller size makes it possible to 3-hole punch the records without obliterating any information.
Use yellow for highlighting if you plan to make copies of the highlighted records. The yellow color will not show up on the copies while other highlighter colors will.
Tag any non-medical records documents that came with the medical records or were intermixed with the medical records. Non-medical record documents include, but are not limited to, incident reports, attorney letters, internal memos, copies of subpoenas, and letters or reports from copy services.
Do not destroy any non-medical documents. Law firms may include some of the documents, such as subpoenas, within a separate section of the records binder. Letters, even those from attorneys, may be included as part of the medical records in some instances.
Rotate "sideways" (landscaped) documents so that the headings of the documents all face the same way. Once the documents are in a binder, this prevents the need to flip the binder back and forth.
Note any gaps in the records such as missing nursing notes or lab results. Pay particular attention to documents that are numbered (page "x" of "x") to ensure that the pages are complete. Notify your attorney of all missing or incomplete medical records.
Duplicate records can be removed and placed in a separate folder if they are truly duplicates. Sometimes records may appear to be duplicates but the other will have a signature and one will not or one will have a notation on it and the other will not. When that occurs, keep both documents.
Blank nursing notes and progress notes can be removed and placed in your separate folder. Keep all blank copies of medication administration records and treatment administration records if the blanks are the back side of two-sided forms.
Multi-part forms, such as nursing flowsheets, don't always have the date listed on each page of the flowsheet. It can be very easy to get confused if the records get mixed up. If multi part flowsheets are important to the case, they can be carefully taped together so that they make sense. If you do not want to do that and the forms are important to the case, place a piece of colored paper between each date.
To separate documents within categories, place a blank piece of colored paper between sections. For example, If you have a Rehab category, colored paper can be placed between Physical Therapy, Occupational Therapy, and Speech Therapy sections.
It is easier to keep numbered documents in their numerical order even if it means that the documents are not in date order. Lab results and other electronic medical records are often numbered this way.
If lab results are NOT numbered, the results are organized by the date the specimen was collected, not by the date reported.
Even though it seems that it would be more time consuming, it is easier to organize voluminous records twice. The first organization is to generally arrange the records in category order or by chart section. The second organization is a more detailed review of the records to put them in chronological order and to ensure that all the records are for the intended patient. Occasionally a page from another patient's records may be found.