Review of medical records

Dr. Zünkeler performs independent reviews of medical records, diagnostic imaging studies, and other documentation for insurance companies, legal professionals, hospitals, and other administrative bodies, on behalf of both plaintiffs and defendants. It is important that Dr. Zünkeler be provided with the imaging studies themselves on CD (whenever possible), not just the radiology reports. Depending on the situation, an in-depth review of the records and diagnostic imaging studies of an individual with a complex brain, spine, or peripheral nerve issue may allow insights into causation, conformance with the standard of care, and neurosurgical case and complication management.

In some instances, an independent review of the treatment records of several patients of a single medical provider is requested in the context of an external peer review. The request for an external peer review is sometimes made by the medical staff of a hospital or by the legal representative of a medical provider in preparation for an administrative hearing.

A careful review of a complete set of medical and administrative records and relevant imaging studies can provide an experienced reviewer with valid insights. A written report based on a record review may be able to address the following issues:

  • appropriateness of medical/surgical care,
  • conformance of medical/surgical care with available evidence-based guidelines,
  • adherence to applicable quality and safety standards,
  • observance of institutional rules and bylaws,
  • impact of pre-existing and subsequent comorbid medical conditions,
  • causal relationship of medical/surgical care to specific events (e.g. an injury), and
  • future treatment needs and costs, including diagnostic testing and follow-up visits.

Even the most careful review of available medical records and diagnostic imaging studies is limited because of its reliance on the quality and completeness of documentation by other healthcare providers and on the quality and completeness of other records, including diagnostic studies, provided for review (i.e. other records and studies may exist that have not been provided). An experienced reviewer may be able to specifically point out such deficiencies to a client who may then be able to obtain them.

A record review can help to establish a basis on which to form valid opinions, but there are three main caveats:

  • the reviewer does not physically examine the patient,
  • the reviewer cannot obtain a verbal history, and
  • the reviewer may not have a complete set of records/imaging.

In some instances, it may be possible and helpful to schedule an IME after a record review has been completed. Depending on the specific circumstances of the case and only when such contact is lawful and specifically authorized, direct communication between the reviewer and treating healthcare providers can add valuable information. In some cases, obtaining a copy of rules and bylaws of the hospital or outpatient facility where medical/surgical care was rendered can additionally be helpful.

The time frame for a record review varies depending on the record volume and case complexity. In most cases, we request a minimum of a 1-month lead time upon receipt of the medical records and imaging studies to conduct the review and create a typed report.