Future Medical Cost Projections Module 10 Records Assessment, with handout Hi. Welcome to Module 10 of the InSitu Academy training program for Future Medical Cost Projection. My name is Kathryn and I will be guiding you through the training program.  .  

Copyright InSitu Academy Records Assessment Chronology of records Chronology of billing statements Summary of medical history Not used for causation determination Facts, non-interpretive Our focus for Module 10 will be the assessment of medical and billing records and how they fit into the narrative report of the cost projection report. We will address how to create a chronology of the records including the format and necessary sections of the chronology for the narrative report. Medical and billing statement records are factual and non-interpretative. They are not used for determining the cause of the injury, but provide a history of treatment. A summary of the medical history will indicate the recommended future treatment for the individual. You will need both Excel and Word programs on your computer to complete the cost projection report. Copyright InSitu Academy

Chronology Prepared in xls spreadsheet format Portrait view Will be inserted into narrative report Associated with this module is a handout for the chronology of the medical records. Please print a copy of the handout in portrait view as we will be referring to sections in the document to understand how to develop a chronology of the medical records. When completed the chronology will be inserted into the narrative report. You may develop your own template or obtain the document through the InSitu Academy’s subscription service. Copyright InSitu Academy

Copyright InSitu Academy Sections Header Footer Columns Rows The medical records chronology document is in the basic Excel format. There is a header at the top of the page indicating the type of document and the client information. There are 3 columns and the number of rows and pages will depend on the amount of medical record information available. Maintaining the document in the portrait view allows the information to be easily inserted into the narrative report. Copyright InSitu Academy

Copyright InSitu Academy Header Client name DOB Attorney Work Product Medical Records Chronology Prepared by Date prepared Date updated The header on the medical records chronology template includes the following information: the title of the document, indication that it is an attorney’s work product, the client’s name and date of birth, who prepared the chronology, the date the chronology was prepared and the date(s) of any updates made to the chronology. Be consistent in the approach for all medical records chronologies.   Copyright InSitu Academy

Copyright InSitu Academy Footer Name of client Page number The footer of the medical record chronology template should include the name of the client and the page number of the report. There may be several pages to the medical record chronology report depending on the amount of medical records to be reviewed. If you are not familiar how to set up the header and the footer in Excel, please open your Excel program. Depending on the version of Excel that you have some items may vary. Across the very top row, usually in green, click on “Insert”, find Headings & Footers to the far right on the second row of icons. Click on the “Header & Footer” icon. You will then be able to modify and/or create your own header and footer. Copyright InSitu Academy

Copyright InSitu Academy Columns Date Provider Notes CPT code, optional Billing, optional Please refer to the column headings on the medical records chronology template hand out. You will be inserting into the date column the actual date the medical record information you are reviewing was transcribed to the record. In the provider column you will be writing/typing in the name of the provider at the time of the medical record transcription. This could be a physician’s name or another professional’s name or their functionality of the care provided. Examples are: Physical Therapist, Occupational therapist, Radiologist. Always remember to designate the title of the professional identified. In the notes section, you will provide a brief description of the information needed for the medical records chronology. Optional columns may be added to the template for identifying CPT codes and billing information. CPT codes and billing information assist in describing procedures and may add clarity to the information in the notes.   Copyright InSitu Academy

Copyright InSitu Academy Date List month, day, year Various years included in medical records Include all records provided by attorney Sort by date when finished No need to sort records before preparing the chronology The date for the notation should be the original date of the entry into the medical record. Record it by month, day and year in the date column. There could be several years of medical records to review for the case. Therefore, it is essential to have the correct date for the notation. Remembering that this is a chronology you are developing, the information can be sorted by date when all records have been reviewed and entered onto the template. In doing this you are not “wasting” time trying to maintain the records in their order of entering.   Copyright InSitu Academy

Provider Physician demographics List last name first List specialty or practice name Hospitalization Name of hospital and location Details in note section Surgery Put SURGERY in caps (easy to find) Diagnostics Use lower case for ‘diagnostic’ Now we will discuss the information that should be entered under the provider column. If the notation is for recording physician’s information, list the last name first, then first name or initial in the provider column. Beside the physician’s name, record their specialty or practice name. If the notation is for a hospital visit, record the name of the hospital and its location in the provider column. Record details of the hospital visit in the notes section. When transcribing surgery information, it is best to record SURGERY in all capital letters in the provider column for easy reference. Details of the surgical procedure are then recorded in the notes section. Using the term “diagnostics” in the provider column may include an MRI, CT scan or x-ray results that are pertinent to the case. Again, the details of the diagnostic exam are recorded in the notes section. Copyright InSitu Academy

Copyright InSitu Academy Notes Brief summary of medical records Facts only Limited abbreviations Check for spelling In the notes section of the chronology template record a brief summary of the event reviewed making sure all important information has been included. The information should be factual and without opinions or conclusions. Medical records tend to have many abbreviations in their documentation. Understanding that the preparation of the document is for non-medical people it is best to limit the use of abbreviations and spell out all words. When completed, spell check the information for spelling errors.   Copyright InSitu Academy

Copyright InSitu Academy Encounters: Notes Chief complaint, medications, treatment plan Office visits Type, body part, impression Diagnostics Procedure and body part, hardware placement Surgeries type and body part Injections Admit/discharge date, summary, procedures, diagnoses Hospitalization List start, stop dates, limited details Physical therapy There are many different types of encounters that will be recorded in the notes section and are important to the case. They may include office visits where the chief complaint, any medications and the treatment plan would be recorded. When recording diagnostics, be sure to include the type of exam, the body part examined and the final impression of the exam. Surgery information should include the name of the procedure, the body part operated on and if there was any hardware placement during the procedure. Hardware placement documentation is important for identifying future surgeries for the removal on the cost projection report. When recording injections indicate the type of injection, the body part injected and the outcome. Hospitalizations should include a variety of information including admission and discharge dates, a summary of why the stay was necessary, any procedures performed and the diagnoses that were applicable on discharge. For physical therapy list the start date and the date the therapy was discontinued. Provide limited details of the therapy. Although there may be volumes of physical therapy notes in the medical record, this one summary is generally all that is needed for the chronology. Copyright InSitu Academy

Copyright InSitu Academy CPT code Optional column Helpful in certain cases Helps with researching future treatment codes Remember that Current Procedural Terminology or CPT codes are standard, universal codes that are applied to medical procedures and services for the purpose of patient records. They are uniform codes that translate the same for doctors, hospitals, patients, and insurance companies. Adding a column on the chronology template is optional but may assist in understanding certain cases and in researching future treatment codes. They can be found in the medical record of the client. Copyright InSitu Academy

Copyright InSitu Academy Will show both billed and paid rates Use rate appropriate for state (collateral source rule) Helps research efforts Billing Billing records are helpful in that they show both the billed rates (usually the full price) and the paid rates (what was paid based on negotiated insurance or Medicare rates). This assists in determining the price of future health care needs on the cost projection report. The collateral source rule prohibits the admission of evidence that the plaintiff or victim has received compensation from some source other than damages sought against the defendant. Example: in a personal injury action the evidence that the plaintiff’s medical bills were paid by medical insurance or Worker’s Compensation is not generally admissible. However, most state have made adjustments to the rule and allow compensation evidence so reimbursement for injuries cannot be recovered twice for the same damages. It is important to know the collateral source rule for the state you are working in.   Copyright InSitu Academy

Copyright InSitu Academy Narrative Report When chronology finished, sort by date Can finish some sections of narrative report when chronology finished Accident description List of diagnoses Treatment history After sorting the chronology by date, you will be able to finish some sections of the narrative part of the cost projection report. The narrative report is created in a Word document. At this point you can add a description of the accident, a list of the diagnoses and the treatment history of the injury. Let’s take a closer look at each of these for the narrative report. Copyright InSitu Academy

Copyright InSitu Academy Accident Description Make a brief statement on type of injury or accident On the narrative report is a section to make a brief statement describing the type of injury incurred or a description of the accident. This is obtained from the medical record and is based on factual information without inserting opinions or conclusions.   Copyright InSitu Academy

Copyright InSitu Academy List of diagnoses Prepare a list of diagnoses and conditions for narrative report Insert into narrative report section Diagnoses can be found in the medical record. List out the diagnoses and conditions and insert into the narrative section of the report. Copyright InSitu Academy

Copyright InSitu Academy Treatment History Copy/paste chronology into narrative report Now that the chronology of the medical and other records is complete, you can copy and paste the information into the Treatment History section of the narrative report. This may increase the narrative report by several pages, but is necessary to complete information required for the case. Copyright InSitu Academy

Medical Recommendations May have recommendations clearly defined in medical records, quote statement and date May have to extrapolate recommendations from ‘gist’ of records Provide statement that following standard protocol if no recommendations available Document any recommendations found in the medical records in the Medical Recommendations section of the narrative report. Indicate that the statements are a direct quote and the date they were placed in the record. You may find the recommendations to be clearly defined or more or less vague, requiring you to interpret recommendations from the “gist” of the records. If no recommendations are found in the medical record, provide a statement that standard protocol will be followed for the injury. Copyright InSitu Academy

Copyright InSitu Academy Home Work 1 Research collateral source rule for your state, download and retain 2 Contact local attorney and volunteer to prepare a medical chronology for 1-2 cases Listed on Slide 19 are activities for follow up and learning. Completing these activities will assist in understanding the collateral source rule for your state. Ask a local attorney for permission to volunteer to prepare a medical record chronology for 1-2 cases. You may want to do one that someone else did earlier to see how you compare. Upon completion of homework assignment, please write a summary or overview and submit to InSitu support team for review. A Certificate of Attendance for CEU credit will be issued after the summary/overview is submitted. Copyright InSitu Academy

Copyright InSitu Academy Contact Information info@insituacademy.com Thank you for joining us for preparing a chronology of the medical and billing records and initiating the narrative report. We hope you have found the information beneficial. Please contact info@insitutraining.com for any questions or assistance Copyright InSitu Academy