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How Do You Review And Analyze Medical Records?

Medical Records

Medical records are valuable legal documents required for medical records analysis in personal injury, medical malpractice, social security disability, workers’ compensation and other cases that rely on medical evidence. Such a thorough and discerning review of the medical records is vital when it comes to building a claim or defence in a legal proceeding. The review process itself can be highly challenging because the medical records are long, complex, and contain medical jargon that people outside the medical fraternity cannot understand. That is why most attorneys and their legal teams choose to outsource the medical record review process.

What Does Medical Record Analysis Involve?

In the language of the common man, it is a detailed search, review, evaluation, and interpretation of medical records. A professional medical review team comprising physicians, registered nurses, pharmacists, documentation experts and others perform the review. For this team, the analysis and summarization of medical records is easy because they have excellent knowledge of medicine and are experienced in the review process.

The relevant medical records are requested through a formal process, and to make the request one needs to identify documents relevant for each case. While the medical records that directly apply to the case are first recognized and requested for review purposes, additional providers that may be relevant are identified during the review. These records are requested if they are pertinent to the case. With medical record review, attorneys can more easily identify the strong and weak points of their cases.

What Information Does A Medical Records Analysis Provide?

  • Identifies missing, incomplete, or redacted medical records
  • Chronology of all medical encounters or events
  • List of all medical providers
  • Details of injuries/illness
  • Factors that contribute to alleged injuries/illness
  • Helps identify standards of care and regulatory requirements
  • Professionally researched and summarized supporting medical literature
  • Succinct, fully referenced reports detailing medical facts/issues relevant to a case, and needed to screen that case for merit
  • Medical records that are correctly indexed, paginated, date stamped and organized according to date, provider, type of document, or customized data fields

Types Of Medical Record Analysis

Medical Chronology: This is a summary of healthcare events presented chronologically. A reliable medical chronology requires clearly understanding and reading through voluminous medical records to highlight key points, interpretation, diagnostics, disease progression and such other information. Medical chronologies are drafted in a way that attorneys, juries, and the general public can easily understand.

The medical chronology is helpful in cases where the following are required:

  • You need to find out if there is a pattern of care the claimant received
  • You want to identify whether the claimant has any undeclared prior medical history that could have contributed to the illness or injury
  • You want to examine the dates because they are relevant to an alleged injury.

Medical Summary: A medical summary provides an expert medical interpretation and opinion that is relevant to the case. This is designed as a detailed narrative summary providing the following information:

  • List of providers and all details such as who, what, when and where, relating to all medical professionals
  • Diagnoses regarding the claimant’s medical condition
  • Lab tests, other investigations the claimant underwent, and their results
  • All details about the treatment plans, surgeries, medical equipment received and being received by the claimant
  • Details regarding medications and their dosages that the claimant is taking/has taken

So, When Do You Need A Medical Summary?

  • You require a high-level overview of the case
  • You need to focus on a specific set of plaintiff allegations that you believe can help prove your case
  • You want a summary of the various medical facts to draft a settlement demand letter

Why Utilize Medical Record Review Services?

Medical record review is best done by a team comprising physicians and legal nurse consultants with a medical background and the necessary expertise. This ensures that the information pertinent to the case is extracted from the hundreds of thousands of data points in the medical record. While the reports are comprehensive, aspects of the medical record that are irrelevant to the case are not included in the chronology or summary. Another important benefit of utilizing medical review services is that attorneys and their legal teams can save considerable time, costs and effort.

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