Expert Medical Documentation Assessment and Review in Emergency Medicine

Are you providing your clinicians with a comprehensive peer review of their medical documentation?
Can you provide quality improvement solutions for your clinicians’ documentation skills?
Do you want to know if your medical record documentation leaves you open to malpractice claims?

Your first defense against a malpractice claim is a complete, legible, and understandable medical record. We review your records and provide you with individual recommendations to achieve that goal. We provide you with real, actionable recommendations based upon a complete assessment of a clinician’s actual medical record documentation.

You need to have your clinicians’ medical records systematically reviewed by experts in emergency medicine and pediatric emergency medicine. We will review physician, physician assistant, nurse practitioner, nurse, and EMS records, providing you with a comprehensive assessment of the strengths and weaknesses of the documentation. We then provide the clinician with recommendations for improvement based upon the individual review.

We review random records from individual clinicians or we can review high-risk records such as chest pain, abdominal pain, headache, fever in infants, and other symptom complexes.

We review each record on several scales to give the clinician a complete picture of their documentation. We assess the complete record on such items as

		Completeness
		Thoroughness
		Appropriate reassessment
		Medical decision-making
		Concordance with other health provider documentation
		Discharge instructions

Our fees are based upon the number of clinicians being reviewed and the number of cases that are reviewed for each clinician. We recommend at least 5 records in each high-risk category or at least 20 randomly selected records for each clinician.

Contact us today for a quote or for additional information. Whether you use handwritten charts, templates, or an electronic medical record, you will benefit from our assessment.