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Hardenbergh Group

The Importance of Complete Medical Records


Health care organizations often struggle to develop a peer review program that is unbiased and meaningful. In an effort to obtain a truly objective review, many organizations turn to MDReview for external peer review. One of the key elements of effective external peer review is that the final report withstand the scrutiny of the provider under review as well as the medical executive committee or other hospital medical staff leadership that requested the review. The review must be free of any hint of bias in order for its findings to hold up under such scrutiny.


One of the downsides to the electronic health record (EHR) is that it generates hundreds, sometimes thousands, of pages of records for virtually every hospital encounter. When engaging MDReview for an external review project, our clients often ask why it’s necessary to send all medical records in addition to other items we often request, such as pre- and post-procedure office notes and any preoperative, intraoperative, or postoperative imaging.

We appreciate the sometimes arduous task presented by providing what are often voluminous records to MDReview for us to then sort and provide to our selected expert reviewer. We often get requests from client facilities to accept only selected portions of the medical record that seem relevant to the issues being reviewed. Others prefer to redact, edit, or condense records to make the job of transmitting them more efficient.

In an effort to provide our clients with high quality peer review that can withstand scrutiny, MDReview requests extensive records in order to avoid any appearance that the requesting facility or its medical staff leadership was trying to point the expert reviewer in one direction or another by being selective in what records are sent to review, thereby potentially diminishing the value of the review.

Our very strong preference is to leave it to our staff and expert reviewer to decide what is relevant in the way of physician and allied health professional documentation, nursing notes, imaging and ancillary results, and any other aspects of the record they may deem relevant. By providing the entire medical record related to the episode of care under review, the integrity of our reviewer‘s final report can never be called into question as being biased or intentionally limited by having had access to only a portion of the relevant medical record.

When it comes to assessing patient selection, medical necessity, and appropriate preoperative screening, our reviewer‘s determination is greatly enhanced by being able to see relevant preoperative office visits, including the process of discussing risks and benefits, alternative procedures, and appropriate informed consent documentation. Preoperative imaging is similarly relevant to patient selection and medical necessity as well as playing a significant role in determination of the quality of the intervention performed and assessing for appropriate outcomes.