Medical records organization is important for both pre-litigation settlement process and trial preparation in most cases including personal injury. Personal injury attorneys receive thousands of medical records and the paralegals in their law firms may have to review all these records to prepare a medical case chronology and summary report. To review the medical records, the legal staff must be well-versed in legal as well as medical terms and they must have an idea of the nuances of civil litigation.
A medical chronology lists all the medical events/incidents relevant to a particular case in chronological order. Key elements of a medical records chronology in personal injury cases include the following.
- Date of Injury or DOI
- Causation of the injury or illness as reported by the patient
- Diagnosis / diagnoses
- Treatment providers and dates of treatment
- Treatment plan(s) – diagnostic reports, prescriptions and referrals
- Prognosis or the likelihood of recovery
- Permanent impairment, if any
- Future medical needs, if any
- Information about prior as well as unrelated medical treatment, if any
- Summary of physicians’ and nurses’ notes
- Definition of medical terms can be included in a medical summary for quick reference
Attorneys use medical chronologies to –
- support their arguments at settlement conferences
- prove the facts that favor their case
- settle cases rather than proceed to trial
- educate a jury when making an opening statement
- emphasize relevant points during closing
- prepare pre-trial motions for summary judgment
Accurate medical summaries help attorneys understand the various aspects of the case and find the information they are looking for quickly. These summaries can be brief or detailed and can typically include information such as the medical condition of the client, details of the medical personnel they contacted, tests conducted, diagnoses, nature of current treatment plan, medication and dosage. It can also include major surgeries and details of equipment such as pacemakers and hearing aids. While a brief summary provides a condensed overview of the most important issues and events concerning a case, detailed summaries, on the other hand, are quite long and provide a more complete chart of events in a chronological order.
These summaries are useful for attorneys to
- prepare and present exhibits
- show the extent and effects of an injury
- respond to cross-questioning by a prosecutor or during a deposition
- create a convincing compensation demand
Attorneys use brief summaries for
- initial pre-litigation reviews
- reference in situations that may turn down a case
At the same time, attorneys require detailed summaries while accepting a case or while conducting an initial evaluation for a case that is already in litigation.
Challenge Law Firms Face
The major challenge is that paralegals working for attorney may not have training in medical terminology, treatment procedures, and other relevant aspects of the records. Besides, to prepare chronologies and summaries, law firms interview clients to determine what medical records a particular case requires, and the gaps in the interviewee’s testimony can affect the quality and reliability of these reports.
There are also possibilities that paralegals may get confused when determining the medical records relevant to a case, as they have to deal with a large volume of medical records. Also, law firms may not get the information they need, if the records were misplaced, lost, or corrupted.
As a good medical chronology or summary is critical to the outcome of any case, it is best that personal injury attorneys consider professional medical review services to prepare accurate medical chronologies and summaries. While reviewing and summarizing records, professionals pay close attention to references to prior and/or unrelated medical treatment and procedures and they include details regarding prior medical treatment at the beginning of the medical summary.