Hi All:

I’m taking a much-needed break from reviewing medical records and thought I’d write to you about the thought process that goes into reviewing medical records.

Ok, if you recall, the review I am currently working on involves a female patient who had filed a workers’ compensation claim regarding her bilateral wrists/hands. When going through the medical records, I will look for anything that references her subjective complaints, objective findings, and diagnostic studies relating to these body parts. However, there is more to it than just that. Complaints relating to our wrists/hands can also be caused by problems relating to our elbows, shoulders and/or neck. This patient also has those problems, so I have to be on the lookout for those issues as well.

Another thing: When reviewing medical records, I also try to get a feel for how the patient is mentally, if at all mentioned in the reports. For instance, in one report, it was noted she had a flat affect. This is important, so I included that in the record review. Our physical and psychological health are inexplicably intertwined; those of us who have suffered from chronic illness or disease know this all too well.

Another point I’d like to make. It is important for me to let the doctor know where the medical records being reviewed come from.

Case in point:

Medical records from J. Doe, M.D., include medical records from XYZ Hospital. Included in these medical records are MRI scans, CT scans, neurology consult report etc.

In this case, I would type the following:

3/12/01 - MRI scan report of the cervical spine (from XYZ Hospital, interpreted by C. Jones, M.D.) in the medical records from J. Doe, M.D., reveals an impression of 2 mm disc bulge, C3-4; 4 mm disc bulge C5-6; and 1 mm disc bulge/osteophyte formation, C7-T1.

In addition to reviewing all the medical records, an overall picture of what has happened to this patient needs to come together. After doing this work for awhile, it does get easier to see the bigger picture. At first, however, it can be quite overwhelming when doing these record reviews (RRs as they are called).

If you have any questions about reviewing medical records, submit them to me.

Tomorrow and Wednesday mornings, I’ll be going into the office to take patient histories of some professional athletes who have been injured on the job. Cool, huh? And no, I won’t reveal any more information than that!