In any medicine-related litigation, the medical record is the key evidence and chart review is indispensable to extract the medical proof from the records. For example, in a medical negligence claim, the medical records are essential because they provide insight into the clinical judgment the medical practitioner exercised at the time. A good medical record contains the key details of every patient encounter. It would provide information regarding relevant clinical findings, decisions made and actions agreed upon, and about those making and agreeing to these decisions. Besides this, the medical records also contain details about the drugs/treatment/investigation prescribed as well as who is making the record and when. Progress notes, examination findings, monitoring and follow-up arrangements are all included in the records. Handwritten notes, electronic health records, lab reports, correspondence between healthcare professionals, imaging records such as X-rays, photographs, and recordings and printouts from monitoring equipment are all part of the medical chart.
How is a medical record used in a legal proceeding? Or, why is it necessary in a legal proceeding?
- The medical record provides clear information regarding the plaintiff’s injury, its extent and nature.
- Both the plaintiff and defense sides can evaluate the physical injuries and the viability of the case
- Medical experts need the medical records to determine the cause of the injuries. In medical malpractice cases, it helps find out whether the doctors provided reasonable care.
- Medical records are vital to estimate the damages sustained by the injured person.
- The at-fault person can understand the claimant’s pre-existing injuries, if any, and whether that injury contributed to the disability.
Attorneys handling medical records need to ensure the privacy and confidentiality of these records when using them to develop their case. The injured party has to authorize the release of his or her medical records from the healthcare facilities where they have undergone treatment. Typically, such an authorization request will include the patient’s name, social security number, date of birth, patient’s address and the patient account number. The request may be for all the records or for specific records such as those during a certain date range.
- Once all the medical records are available the lawyer needs to review them, and for this comprehensive review process, most attorneys prefer utilizing medical review services.
- The concise medical case summary prepared enables the attorney to understand and review the plaintiff’s life before and after the injury, and thereby determine the exact impact of the injury. This is very important when calculating the damages that the plaintiff is entitled to.
- During the discovery stage, the medical records are made available to the defense counsel in the affidavit of documents since they are relevant to the legal proceedings. This ensures a meaningful discovery process.
The medical records must have clear, accurate, comprehensive, concise, objective, up-to-date, and legible documentation of patient care. Altered, incomplete, or missing medical records can be personally and legally harmful. Whether personal injury lawsuits, criminal cases, workers’ compensation cases, disability determinations, medical negligence or other injury cases, the medical record is the most important document available. They are generally admissible at a trial, and a good medical record can effectively communicate the patient’s status and progress in therapy. Thus, medical records and medical record review are of great significance in personal injury, workers’ compensation, social security disability and such medical legal cases. They have a role to play at every stage of the litigation process.