How to Analyze Health Care Records

Instructor: Misty Baker

Dr. Baker has a doctorate in podiatric medicine and practiced medicine in both the hospital and private practice atmosphere.

Analyzing health care records can be a challenging task! This lesson will discuss what health care analysis is, and how to properly perform the analysis of health care records.

The Analysis of Health Care Records

Sara, a nurse at Sickly Hospital, was just informed that she got a promotion after 15 years of service. With this promotion comes a new job description, including that of Health Care Record Analyst. Sara is ecstatic, but nervous about her new duty. What exactly is the analysis of health care records, and how should she go about performing this new assignment?

What is Health Care Record Analysis?

Health record analysis is, simply put, a comprehensive evaluation of a patient's medical record. You can think of the medical record as a story, since it describes everything that occurred during the care an individual patient received. The actual analysis can vary widely based on the size of the medical facility and the reason the analysis was requested, but a health care record analysis typically includes:

  • The location and organization of all medical records associated with an individual patient.
  • A review of clinical documentation by both nurses and physicians to ensure that: They are in compliance with federal, state, accreditation and possibly Hospice standards; all documentation and paperwork, including the medical facility's required forms, is complete; and all files are properly entered into the facility's database.
  • Interpretation of all clinical documentation to ensure that the submitted billing codes were justifiable and accurate concerning both the actions performed by the facility and each specific diagnosis of the patient.
  • Analysis of the facts located in the individual's medical record.

It is critical that all of this is performed with a high degree of accuracy. The health care record analysis could be a crucial step in preventing law suits and/or insurance reimbursement concerns.

Clinical Documentation in the Analysis of Healthcare Records

Documentation accuracy is the real meat of a medical chart analysis! This portion of the analysis is better understood when the medical record is broken up into five main categories.

History and Physical (H&P)

The H&P section of the chart contains information that was obtained during the first evaluation of the patient, usually by the physician. This usually includes everything from the initial signs and symptoms experienced by the patient to the plan for addressing each condition that was diagnosed.

The H&P section is very important because it will serve as a reference document, with detailed information about the patient's history and initial exam. For example, this section is often referred to whenever medications are prescribed to ensure no allergies exist.

Progress Notes

If a patient's medical record is like a story, then the Progress Notes section is the story's main idea.

Because the progress notes are organized in chronological order, this section is a kind of timeline of events, from the time the patient walks into the facility until they walk out. Valuable information is contained in the progress notes pertaining to the evaluation and care of the patient by the treating physician and nurse, as well as the patient's response to the treatment.

Every progress report should contain the following information:

  • Subjective information. The physician should record in this section statements made by the patient such as how the patient is feeling today or what the patient says about treatments, etc.
  • Objective information. This includes the physical exams the physician performed during that visit and the results of the exams.
  • Assessment. Describes each diagnosis that the patient is suffering from.
  • Plan. Describe the plan of treatment for each diagnosis listed in the assessment. Each progress note should be properly signed and dated by the creator of the report.

Physician Orders

Physician orders are like a list of things that must be performed. An example of a physician order could be to administer a certain medication, specifically listed with dosage and frequency, if a patient's blood pressure rises above a specific amount.

In analyzing this section the health record analyst should look for several things:

  • Is there documentation that supports that these orders were carried out by the appropriate staff member?
  • Were the orders performed (if documentation of the performance exists) in a timely manner?
  • Is the physician's order relevant to the individual patient's diagnosis?

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