How Medical Records Help in Establishing Legitimacy of a Case

by | Published on May 13, 2015 | Medical Record Review

The importance of healthcare documentation in medical litigation cannot be understated. Documenting the patient’s condition and history of care is very important to ensure that appropriate care is provided to the patient; and incorrect information can prove to be hazardous. Proper documentation is also important from a legal point of view because it will help avoid any legal repercussion following some kind of injury caused to the patient. Medical records help to establish the actual health condition of a person and appropriately settle personal injury, medical fraud and other medical litigation. The evidence for such cases is mined through detailed examination, review, analysis and summarization of medical records and related information for the legal environment.

In a recent case involving a Wilsonville chiropractor, the jury decided that there was no merit to the complainant’s $4.7 million lawsuit since they found that the chiropractor was not responsible for the complainant’s severe and debilitating back pain. The accusation was that the chiropractor continued with the procedure called lumbar side posture adjustment in spite of the petitioner crying out in pain and asking her to stop the procedure. The chiropractor testified that she stopped as soon as the petitioner complained of pain.

The plaintiff’s medical records provided evidence that she suffered from degenerative disc disease and it was a pre-existing condition, and that the chiropractor was not responsible for her present debilitating condition. A CT scan that was done a year before the petitioner met the chiropractor showed that she already had a bulging disc. With the evidence provided by the medical records, the jury decided that the chiropractic adjustment was not responsible for the petitioner’s chronic pain.

In yet another case involving a Burlington woman who is charged with feigning loss of sight, voice and mobility as a ploy to defraud the public, medical records played an important part in detecting fraud. The woman was charged with fraud over $5000 in connection with an online fundraising campaign she ran to cover medical expenses for chronic inflammatory demyelinating polyneuropathy (CIDP), a rare neurological disease police say she does not have, going by her healthcare records.

The work that goes into reviewing healthcare records is voluminous and requires considerable expertise on the part of the reviewer. It involves identifying the materials needed as well as the different types of medical documents; organizing the records and analyzing how the evidence therein relates to damages/liability and whether the claim is legitimate; understanding the legal elements involved; creating timelines and summaries and managing the tasks related to all the activities. A comprehensive review is what helps to gather valuable evidence needed to develop a feasible argument.

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