9 Questions a Paralegal/ Legal Assistant May Have When Reviewing Medical Records

by | Published on Jan 28, 2022 | Medical Record Review

Medical records are an important component of medical litigation and are an integral part of the legal process right from the pre-litigation phase. Paralegals entrusted with medical record review, have to closely examine the nuances of the lawsuits pertaining to personal injury, workers’ compensation and medical negligence cases. Here are the answers to some possible questions that a legal assistant might come across while dealing with clients approaching legal firms for assistance in defending their case.

1. Should a paralegal be familiar with medical terms?

For a non-medically trained person, it is essential to do a basic research on the associated medical terms specified in the document. This can help the paralegals to have a clear understanding of the case.  Getting acquainted with relevant chronologies leverages your effort to understand the case more efficiently. For example, in a personal injury case it is crucial to know the location of the injury and the medical terminology relevant to the injury and its location. Similarly, there will be abundant use of medical abbreviations in medical records. Unfamiliar abbreviations have to be charted and expanded by referring to authentic sources.

2. Is it important to know the circumstances surrounding the case of the client?

Prior to collecting medical records, it is imperative to understand the nature of the case. Your client approaches your law firm for cases related to personal injury, workers’ compensation, medical negligence etc. There can be instances where paralegals are the first point of contact for potential clients. Client interview gives a deeper understanding of the circumstances surrounding the case. An accurate assessment of the case is necessary for classifying the required documents on the basis of relevance, so that it is useful for different stages of the litigation.

3. How to determine the relevance of the medical records that has to be retrieved?

Medical records are very expensive and you have to be careful while gathering the required documents. For example, if you are dealing with a personal injury case, the details of medical history related to prior fever or infections are unwarranted. However, you have to obtain documents of treatments undergone by the patient due to the injury and also any prior incidents of injury, if any. It is better to prepare an inclusive list of the required documents so that you won’t end up missing records with pertinent data.  A detailed discussion with the client gives an insight into the dimensions of the case.

4. What are the pre-requisites for accessing medical records from health care providers?

The client has to be requested to fill a form listing the details below:

  • Identify the care providers and physicians related to the case with names
  • Dates of the patient visits
  • Care received in the ER, if any
  • Medications and treatments administered
  • Outcome of the treatment
  • Diagnostic test results
  • The phone number and addresses of the care providers

Familiarize with HIPAA requirements

Paralegals are entrusted by attorneys to study the case and aid the litigation process. There are federal regulations in the form of HIPAA in place to preserve the confidential and sensitive information of patients. Therefore, paralegals have to mandatorily comply with HIPAA while requesting medical records from health care providers. When a request for medical records is issued to the health care providers, a set of directives will be released. Paralegals have to ensure that these directives are adhered to while gathering the records.

5. Is client authorization mandatory to access the records?

HIPAA authorization is not the only form that is required while accessing the medical records. It is crucial to obtain the client’s authorization as soon as possible. The client has to be requested to complete an “authorization for disclosure of protected health information” form. Additionally, there are several authorizations in use and the authorization requirements are different for different health care providers.

6. What is the scope of request?

A record request should be specific because being too broad will be confusing, and you may end up retrieving unnecessary documents. If the details of the care received in the ER are to be accessed, then the request should include the date of the incident along with the medications administered and the diagnostic results. For example, if blood results are all that is needed, then it has to be specifically mentioned in the request. Efficient planning at this stage can considerably contain the costs.

7. What is the timeline to procure the medical records?

  • The list of medical reports has to be gathered soon after the attorney has decided to review the case. The requested medical records might be obtained after quite a long time as these records are to be retrieved from multiple sources (hospitals and physicians).
  • Enquire with the attorney the appropriate time to collect medical bills, pharmacy bills or prescriptions to calculate the damages.
  • Records from third-party payers have to be collected as the clients might not be aware of the treatment received from additional healthcare providers. This can enable you to request for additional medical records.
  • The response received from health practitioners may not be the same. Either the records are issued promptly once the request is placed or there can be considerable delay in issuance. The whole process requires multiple requests and the timeline of these requests has to be tracked.

8. What should be done after retrieving the necessary medical records?

  • Medical record organization has to be done before extraction of the required details via medical records review. While organizing the records, the focus should be on the question, “How the records can defend the plaintiff’s case”.
  • Cross-verify the records with the itemized billing statement from the medical provider. Specifically, the date of service has to be cross-checked as any anomaly in the data can affect the merits of the case.
  • Analyze the medical records to find discrepancies.
  • Add subsections like, “Progress notes”, “Clinical observations”, “Laboratory” and “Radiographic”.
  • Major sections of the medical records that are crucial for the case have to be tagged and indexed. This eases the maintenance of the records.
  • Ensure that the complete set of medical records has been received.

9. How to ensure that the entire set of medical records has been received?

Keeping track of the medical records is an important part of medical records review. Annotating the documents by page number is referred to as Bates stamping of records. Therefore, Bates stamp the records by assigning unique numbers to each page of the medical records. It can be done electronically or manually.  Communicate with the attorneys about their preference in numbering the pages. It is because medical records arrive in reverse chronological order (most recent information first). However, some attorneys prefer to keep the records in chronological order based on date and time order.

Paralegals assist the attorneys in the preparation of legal arguments of a case. It is important to maintain the confidentiality of sensitive healthcare information of the patients to uphold attorney/client privilege.

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