Medical Records Management - Technical Specification

Document and medical record management system

Purpose

The Medical Records Management module handles the storage, tracking, and retrieval of all medical documentation related to legal cases. This includes medical bills, lien documents, imaging studies, therapy notes, surgical reports, and other healthcare documentation. The system maintains document versioning, tracks document status, ensures HIPAA compliance, and integrates with claim processing and case management workflows.

Key Concepts

Term	Definition
Medical Record	Any healthcare-related document for a case
Document Type	Category of medical documentation
Medical Bill	Invoice for medical services
Lien Document	Legal claim on settlement for medical costs
Imaging Study	X-rays, MRIs, CT scans, etc.
Operative Report	Surgical procedure documentation
Therapy Notes	Physical therapy progress notes
Document Status	Current state of document processing
OCR Processing	Optical character recognition for data extraction
Document Retention	Legal requirements for keeping records

User Roles

Role	Description	Permissions
Records Manager	Manages all medical records	Full CRUD
Medical Records Clerk	Uploads and categorizes documents	Create, Read, Update
Case Manager	Reviews case-related documents	Read only
Provider	Submits medical documentation	Create, Read own
Attorney	Reviews case documents	Read case documents
Auditor	Compliance review	Read, Audit access
System Administrator	System configuration	All permissions

Field Documentation - Medical Record Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique record ID	Auto-generated CUID	Primary Key
Document Number	String	Yes	Human-readable number	Format: MR-YYYY-XXXXXXX	-
Legal Case	LegalCase	Yes	Associated legal case	Must be active case	LegalCase
Patient	Patient	Yes	Related patient	Must match case patient	Patient
Document Type	String	Yes	Type of document	Enum: Medical Bill, Lien, Imaging, Op Report, Therapy Notes, Lab Results, Prescription, Other	-
Document Sub Type	String	No	Specific document category	Based on document type	-
Document Name	String	Yes	Descriptive name	Max 200 chars	-
File Name	String	Yes	Original file name	With extension	-
File Path	String	Yes	Storage location	Secure path	-
File Size	Integer	Yes	Size in bytes	Positive integer	-
File Type	String	Yes	MIME type	Valid MIME type	-
File Extension	String	Yes	File extension	pdf, jpg, png, tiff, etc.	-
Provider	ClinicalProvider	No	Source provider	If applicable	ClinicalProvider
Vendor	Vendor	No	Source vendor	If applicable	Vendor
Service Date	DateTime	No	Date of service	For bills and records	-
Received Date	DateTime	Yes	When document received	Auto-set on upload	-
Document Date	DateTime	No	Date on document	From document	-
Page Count	Integer	Yes	Number of pages	Positive integer	-
Document Status	String	Yes	Processing status	Enum: Pending, Reviewed, Processed, Rejected, Archived	-
Status Reason	String	No	Reason for status	Required for Rejected	-
Status Date	DateTime	Yes	When status changed	Auto-updated	-
Status By	User	No	Who changed status	Valid user ID	User
Review Required	Boolean	Yes	Needs review	Default true	-
Reviewed By	User	No	Who reviewed	Valid user ID	User
Review Date	DateTime	No	When reviewed	Set on review	-
Review Notes	Text	No	Review comments	Max 2000 chars	-
Is Bill	Boolean	Yes	Is medical bill	Default false	-
Bill Amount	Decimal	No	Total bill amount	Required if bill	-
Bill Number	String	No	Provider bill number	If available	-
CPT Codes	String	No	Extracted CPT codes	Comma-separated	-
ICD Codes	String	No	Extracted diagnosis codes	Comma-separated	-
Is Lien	Boolean	Yes	Is lien document	Default false	-
Lien Amount	Decimal	No	Lien claim amount	Required if lien	-
Lien Holder	String	No	Who holds lien	Required if lien	-
OCR Processed	Boolean	Yes	OCR completed	Default false	-
OCR Date	DateTime	No	When OCR'd	Set after OCR	-
OCR Confidence	Decimal	No	OCR accuracy score	0-100 percentage	-
Extracted Data	Text	No	OCR extracted data	JSON format	-
Is Confidential	Boolean	Yes	Extra security	Default false	-
Retention Date	DateTime	Yes	When can be deleted	Based on retention policy	-
Retention Policy	String	Yes	Retention rule applied	7 years default	-
Source System	String	No	Where document originated	Portal, Email, Fax, etc.	-
Related Claim	Claim	No	Associated claim	If applicable	Claim
Related Appointment	Appointment	No	Related appointment	If applicable	Appointment
Related Authorization	Authorization	No	Related auth	If applicable	Authorization
Version Number	Integer	Yes	Document version	Starts at 1	-
Previous Version	MedicalRecord	No	Prior version	For versioning	MedicalRecord
Is Current	Boolean	Yes	Latest version	Default true	-
Checksum	String	Yes	File integrity hash	SHA-256 hash	-
Encrypted	Boolean	Yes	Is encrypted at rest	Default true	-
Compression	String	No	Compression type	If compressed	-
Thumbnail Path	String	No	Preview image path	For images/PDFs	-
Full Text	Text	No	Searchable text	For text search	-
Tags	String	No	Document tags	Comma-separated	-
Access Count	Integer	Yes	Times accessed	Incremented on view	-
Last Accessed	DateTime	No	Last access time	Updated on view	-
Last Accessed By	User	No	Who last accessed	Valid user ID	User
Archived	Boolean	Yes	In archive storage	Default false	-
Archive Date	DateTime	No	When archived	Set on archive	-
Created At	DateTime	Yes	Upload timestamp	Auto-generated	-
Updated At	DateTime	Yes	Update timestamp	Auto-updated	-
Created By	User	Yes	Uploading user	Valid user ID	User
Updated By	User	Yes	Updating user	Valid user ID	User

Workflows

Document Upload Workflow

1. File Upload

   • Select legal case
   • Choose document type
   • Select file(s)
   • Add metadata

2. Validation

   • Check file type allowed
   • Verify file size limits
   • Scan for malware
   • Generate checksum

3. Processing

   • Store in secure location
   • Create database record
   • Generate thumbnail
   • Queue for OCR

4. OCR Processing

   • Extract text
   • Identify data fields
   • Extract amounts
   • Store extracted data

5. Review Queue

   • Add to review queue
   • Assign to reviewer
   • Send notification
   • Track review status

Medical Bill Processing Workflow

1. Bill Receipt

   • Upload medical bill
   • Mark as bill type
   • Enter bill amount
   • Link to provider

2. Data Extraction

   • OCR processing
   • Extract bill number
   • Extract CPT codes
   • Extract amounts

3. Validation

   • Verify provider
   • Check for duplicates
   • Validate amounts
   • Match to services

4. Claim Creation

   • Create claim record
   • Link to document
   • Process for payment
   • Update case records

Lien Document Workflow

1. Lien Receipt

   • Upload lien document
   • Mark as lien type
   • Enter lien amount
   • Identify lien holder

2. Verification

   • Validate lien holder
   • Check legal validity
   • Verify amounts
   • Review terms

3. Recording

   • Record in lien registry
   • Update case liens
   • Calculate total liens
   • Alert case manager

4. Settlement Processing

   • Include in settlement
   • Calculate lien portion
   • Process payment
   • Release lien

Document Retrieval Workflow

1. Search Request

   • Search by case
   • Filter by type
   • Date range
   • Text search

2. Access Control

   • Verify permissions
   • Check confidentiality
   • Log access
   • Apply redactions

3. Delivery

   • Display document
   • Provide download
   • Track usage
   • Update access count

Business Rules

Upload Rules

• Maximum file size: 50MB
• Allowed formats: PDF, JPG, PNG, TIFF, DOC, DOCX
• Must be associated with active case
• Duplicate detection by checksum
• Automatic virus scanning required

Retention Rules

• Medical records: 7 years minimum
• Legal documents: 10 years
• Financial documents: 7 years
• Archived after 2 years inactive
• Permanent retention for major cases

Security Rules

• Encryption at rest mandatory
• HIPAA compliance required
• Access logging for all views
• Confidential docs need extra auth
• PHI redaction when required

Version Control Rules

• New version maintains history
• Previous versions read-only
• Current version flag maintained
• Version notes required
• Maximum 10 versions per document

Integrations

System	Integration Type	Purpose
Document Storage	File System/S3	Secure file storage
OCR Engine	API	Text extraction
Claim System	Direct Database	Bill to claim conversion
Legal Case System	Direct Database	Case association
Email System	SMTP/IMAP	Document receipt
Fax System	API	Fax document receipt
Virus Scanner	API	Malware detection
Full Text Search	Elasticsearch	Document search

Common Issues

Issue	Description	Resolution
OCR Failure	Text extraction fails	Manual data entry
Duplicate Document	Same document uploaded	Merge or link records
Wrong Case	Document on wrong case	Move to correct case
Corrupted File	File won't open	Request reupload
Missing Pages	Incomplete document	Request complete version

Screenshots Needed

• Document Upload Interface
• Document Search Grid
• Document Viewer
• OCR Review Screen
• Medical Bill Processor
• Lien Management View
• Document Categories
• Batch Upload Tool
• Document Timeline
• Access Log Report

Performance Considerations

• Upload processing < 5 seconds
• OCR queue processing time
• Support 100GB+ storage per case
• Quick document retrieval
• Efficient full-text search

Security Considerations

• HIPAA compliance mandatory
• Encryption at rest and in transit
• Access control lists
• Audit trail for all access
• Secure deletion process
• PHI handling procedures

Notes

• OCR accuracy improves with training
• Cloud storage migration planned
• AI-powered data extraction in development
• Mobile document capture app planned