Medical record review for medical malpractice cases is mainly conducted to identify the strengths and weaknesses of a particular case. It also helps identify any deviation from the expected standards of care. A comprehensive review of the medical records helps determine merit and causation. For the medical malpractice attorney and his/her legal team, the process of medical record analysis can be very tedious and time-consuming. This is mainly because of their non-medical background and unfamiliarity with aspects such as standards of care and how to apply those in the particular case they are handling. That is why many attorneys hire an experienced medical review team to review the relevant medical records and prepare an easy-to-understand report they can use.
Types of Medical Malpractice Claims
Here is a list of the common types of medical malpractice cases that need medical record review.
- Wrong diagnosis or delayed diagnosis: These are very common medical mistakes that often prove very costly. Studies show that heart attack and cancer are among the most commonly misdiagnosed conditions. Such failure to diagnose serious health issues can lead to patient harm, and even death. It may result in inappropriate treatments. When diagnosis is delayed, the patient doesn’t receive timely treatment. What are the main reasons for wrong and delayed diagnosis?
- Fails to identify clinical symptoms
- Doesn’t refer the patient to a specialist
- Fails to request additional information or order medical testing
Apart from the above, there are other factors that can lead to misdiagnosis and delayed diagnosis. For example, mislabeled test results, mistakes that occur when evaluating data or when conducting a test, and missing test results.
- Failure to Treat: When a provider makes this mistake, he/she is violating the standards of care requirements expected of them. Among the reasons for this type of medical error are – discharging a patient too soon from the healthcare facility; failing to request proper medical tests; not providing instructions for follow-up care; and not giving due importance to a patient’s medical history when prescribing a particular treatment or medicine. Another reason for this failure to treat is that the doctor may have more patients than he/she can handle efficiently.
- Surgical Errors/Procedural Errors: These are the second leading cause of medical malpractice claims in the United States. Most of these cases involve the surgeon or his team members leaving tools or sponges inside the body during the procedure, operating on the wrong side of the body, the surgery being performed on the wrong patient, reactions or problems associated with anesthesia, or even failure to adhere to accepted medical practices before, during, and after surgery. Many of these claims allege a failure in communication and many surgical mistakes lead to permanent injury.
- Prescription Drug Errors: These are serious errors involving mistakes when prescribing drugs. Such mistakes include prescribing the wrong medicine for a certain diagnosis, not recognizing possible dangerous drug interactions or allergic reactions, prescribing a wrong dosage, and not recognizing the signs of drug abuse, addiction or overdose that could contribute to health risks. Drugs frequently involved in medical malpractice claims include opioids, anticoagulants, cardiovascular drugs, antibiotics, steroids, and psychotropic drugs.
- Childbirth Injuries: These include injuries that occur due to medical mistakes before, after, or during delivery and could impact the child for his or her entire life. Common errors include improper use of forceps, improper use of vacuum, not responding appropriately to fetal distress, delay in ordering a cesarean section; shaking, dropping, or mishandling a baby during or after birth, and not performing the required specialized tests during pregnancy. Birth injuries due to medical errors include spinal cord injuries, shoulder dystocia or other nerve damage, cephalohematoma, and cerebral palsy. If the doctor does not inform the mother about prenatal health conditions before childbirth, it could be a basis for a medical malpractice case.
Why Medical Record Review Becomes Necessary
Medical malpractice cases pose certain challenges for attorneys and their paralegals. They have to determine whether the physician is liable for the damages caused to the plaintiff, and the nature and extent of the damages. The attorney should also have a good understanding of all the relevant medical events. To understand the medical facts, medical record review is essential. This is best done by professional medical review companies where expert reviewers including legal nurse consultants will analyze the records and prepare a medical case summary that the attorney can easily understand. By outsourcing review of medical records in a medical malpractice case, attorneys can overcome challenges such as the following.
- Handle voluminous, unstructured medical records
- Identify complications
- Identify tampering with the records, if any
- Determine whether the physician deviated from the expected standard of care
- Determine whether there are missing medical records
- Lack of expertise in medicine and difficulty understanding medical terms, abbreviations and jargon
- Handle the investigation burden
An expert medical review company can provide comprehensive review of the medical records in a medical malpractice case. Their findings and the report prepared will enable attorneys to establish the validity of the claim.
At Managed Outsource Solutions (MOS), we organize, summarize and review medical records for medical malpractice cases. Benefit from the expertise of outsourcing professionals and prepare your case well.