The world is a great volume, and man the index of that book – John Donne
Medical record indexing is the categorization of medical records based on specific criteria such as patient identification, diagnosis, or treatment. It enables efficient retrieval and quick identification of relevant information for healthcare providers, researchers, and legal professionals.
Emerging Healthcare Scenario
Disease conditions have seen an abnormal growth in recent times, both from pandemic-related illness and other clinical conditions. Because of this, hospital infrastructures are overwhelmed, and healthcare delivery systems are stretched to their limits. Evidence of this has been on display in the news for the past couple of years.
Fortunately for us, medical science does its best to keep pace with this unprecedented growth and finds new ways to deal with it with more research and development and more deliverables. In addition, world-class medical facilities are being expanded to assist with patient care.
Medical databases are growing as well with an overflow of patient-specific medical records that adds to administrative workloads—more responsibility and accountability.
Medical Records Management — a new pressure point
With tele-visits, drive-in appointments (also known as parking lot visits), and vaccine visits added to the regular physical clinic appointments during the pandemic, the medical records storage challenge is growing like never before. There is every reason to believe that we are heading into a difficult situation with the organization of medical records.
These new additional work-types flow into already stressed electronic health record (EHR) systems. More and more data needs to be managed and organized, for example if there are requests from patients for access to health records. On the institutional side, medical record reviews are done for various reasons, including to help attorneys, insurance underwriters, coders and billers, medical researchers, and medical auditors.
Medical Record Indexing and Categorization
It is common knowledge that indexing helps when dealing with a large, diverse volume of data. Indexing enables you to navigate through mixed pages of records and saves you valuable time rather than manually scanning for key words or what you might refer to as a hunt-and-check search.
Medical records usually contain an assorted type of records such as doctor notes, RN notes, lab notes, radiologic data, call records, utilization reviews, peer-to-peer reviews, declaration of custodian records, WC claim forms, therapy notes, questionnaires, bills for hospital overheads, ambulance charges, and aftercare visit notes; the list is endless. Imagine that you are an attorney trying to wade through this morass of information. It’s not a pretty scene.
Here’s where medical records indexing comes into the picture. Medical record indexing segregates similar documents into a specific page or section. For instance, GA (general admin) sheets go into one particular folder while GM (general medicine) sheets go into another. It is a simple but useful concept that we have all done for business or personal tasks.
Medical record indexing is also a convenient way for the hospitals and healthcare facilities to win over the patients with better ratings in patient satisfaction and care through medical auditing. The auditors can look at a specific data group and focus on improving delivery on that particular front.
Summarization of Records
Often the full set of records are more than needed for a review and abstraction can be very useful. These collected documents are bundled into a single PDF file and categorized as reviewable and non-reviewable pages. The categorization is done at the start of the medical records review exercise. The medical records reviewer first creates a Date, Page Number, and Provider (DNP) sheet before beginning the summarization journey.
A medical record reviewer abstracts all vital information from these pages and puts them together chronologically in an easy-to-retrieve and readable format. The accuracy of the summary generated is proportional to the understanding of the process and the knowledge of the medical records reviewer. Consistency and accuracy are key; reviewers should go the extra mile to ensure no key points are omitted.
Without medical record indexing, attorneys can run into trouble ranging from the inability to locate a specific medical record from a mountain of data. How best to distinguish between copy service paperwork and an injury report? Medical record indexing plays a decisive role in attorneys expediting their cases to win claims for their respective clients in a timely manner.
Medical record indexing is usually outsourced to a third-party provider to save time and to remain cost effective.
Medical records are practically sacred because they carry protected health information (PHI) of a patient. The Health Insurance Portability and Accountability Act (HIPAA) mandates these to be protected at all costs. We should never compromise data security, and any data breach here would severely erode the confidence of the stakeholders. Choosing a third-party medical record review vendor who provides data privacy is imperative. The vendor should encrypt the data with secret keys as an additional layer of data security.
The PreludeSys Advantage
PreludeSys has a proven track record in medical data and records management and we have secured exceptional customer satisfaction for the last 10+ years. This success is powered by a team of flexible, dedicated, review professionals with constantly refreshed skills who are “all in” when it comes to providing abstracts and summaries that attorneys can quickly use to promote a client’s case.
PreludeSys is a market leader in medical record review services and privileged to:
- Offer comprehensive medical record indexing services
- Provide end-to-end data security in medical record review for the past decade
- Has a team that delivers on quality and quick turnaround time (TAT)
- Render cost-effective services that help you save money and time
For more insights, connect with our experts today!