In any medical-legal case, medical records act as testimony to the various treatments provided to the patient. To obtain the required evidence from the records, medical record review is a mandatory process. The review of medical records is rather challenging, especially for legal teams unacquainted with medical terminology and procedures. Evaluation of data in the medical documentation becomes complicated because of difficult medical terms, complex treatment procedures, medical abbreviations, and so on. While some reports may be simple, pathology and radiology reports could present difficulties in terms of comprehension. itcubebpo.com provides an example in an article posted on their site regarding what makes medical record review complicated. They quote the example of a CT scan/MRI scan/radiograph of the spine. In this case, the observations listed are detailed but the final impression could be a short term coined for all the symptoms. This may leave the reviewer wondering why the diagnostic terms used in observation are not considered in the impression. Similarly, medical records in the form of evaluation sheets or flow sheets that contain frequently taken observations, need to be more comprehensively reviewed so that there are no errors in the report prepared for the attorney. Other factors that present difficulty for legal professionals are:
- Large volume unorganized data
- Lack of medical competence
- Organizing and managing the records
- Identifying missing medical records or medical data
Medical chart review that involves medical record organization and accurate interpretation can therefore be time- and labor-intensive. So, how can this process be simplified and made more efficient? The answer is, through medical case summarization preferably by a professional medical review company.
- This involves arranging all the medical records systematically
- All prior treatments, medical/surgical/family histories, and a list of medications and observed allergies are listed clearly
- Diagnosis of the present situation is clearly mentioned in the summary report
- Physicians’ observations and diagnostic studies that support such observations are highlighted
- Treatments are mentioned in a systematic manner so that the medication status, surgeries planned, physicians’ instructions, follow-ups and referrals are all clear
Medical record summaries are prepared on the basis of solid facts, and provide data regarding the who, what, when and where aspects related to the various medical treatments provided. These summaries are convenient for the attorney in that they need not refer to each and every medical record when preparing the case. To prepare accurate summaries, medical reviewers used the latest advanced technology to review, rearrange and interpret the data in the records. Their objective is to prepare a summary that is easy to access and provides a chronological or date-wise view of the various treatments provided to the patient. The records are categorized on the basis of service providers or the type of record. The summary prepared is hyperlinked, and this enables legal entities to process their services at a much faster rate.
The medical case summary can be customized according to individual attorney requirements. It can be comprehensive in the sense that it is detailed with in-depth view of the pertinent information. It can be a simple narrative medical summary that captures and highlights important medical information and other relevant data in a narrative format. It can be an annotated index summary providing an overview of the medical records with brief descriptions of various medical events and dates of service.
Our medical record review company considers the end use of the medical record summaries as per client requirements because they are used for both plaintiff and defense sides. We make the entire medical review process less complicated for attorneys and their office teams. The case summaries we prepare are concise and accurate, and enable our attorney clients to review relevant medical information, and use the data to efficiently develop their case.
What Is A Medical Records Summary And How Is It Useful For Attorneys?