Comprehensive Medical Record Review Support for Social Security Disability Firms
- Front/face sheet – This has all patient demographic information upon discharge such as diagnoses, complications, procedures done, and consultants utilized. It must be checked whether appropriates codes have been assigned to all diagnoses.
- History and physical – These records have information on the current complaint and past medical history, as well as physical examinations, diagnoses and treatment plans.
- Patient progress notes – These are a dated narrative of the patient's disability condition and response to treatment.
- Physician order sheet – This record has details about orders for all treatments tests, medications and procedures done
- Nurses notes – These provide information on the care administered when the patient was in hospital.
- A quick assessment of medical records to help obtain an overview of the claim/case issues
- Determination of providers who rendered care to the patient over time
- Identification of the additional sources from which medical and other records can be obtained
- Identification of missing medical records
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