In any insurance defense litigation involving injuries, a detailed medical record review is the best way to get to know the nature of injuries and their impact on the injured party. If you are an attorney or legal support staff required to summarize and review medical records for causation, treatment and prognosis issues associated with the injured party, you need to maximize your review time. Make sure that you prepare a patient record with the necessary background information so that you will have a complete view of the injured person’s history. This will also be of immense assistance in all activities related to litigation – whether it is to prepare for depositions and trial, value the case, draft settlement proposals or answer discovery.
Here are some important personal details to look for:
- Professional history
- Marital and family status
- Current and earlier medications
- Pre-existing conditions
- Prior illnesses, serious injuries and prior surgeries
- Habits and factors related to life expectancy (alcohol intake, smoking, weight, congenital conditions)
You can include any significant background information at the beginning of the medical summary, which is helpful for anyone on the legal team working on the particular case.
When reviewing medical records to prepare a medical case summary, the first step is to arrange the records chronologically. Depending on the type of case and your personal preference, you can arrange them earliest to latest or vice versa. You cannot risk missing any details because you never know what information may be needed as the case progresses. You need to be alert to details such as the following:
- Entries such as “allergies.”
- Whether the patient is diabetic and this detail is entered in the chart.
- Average baseline blood pressure and respiratory rate in surgical cases.
- Whether any suspicious gaps exist in the records.
- Entries made around shift change times.
A good medical summary will serve as a clear working copy of the medical records. It will help the lawyer/attorney to avoid referring to the medical records again and again. Summaries need to be concise and specific; avoid preparing wordy summaries. Medical summaries have to be written in accordance with the purpose for which they are meant – to review a particular claim regarding its validity or the extent of injuries, to evaluate particular concerns and so on.
A very important requirement for the reviewer is objectivity. This will help to clearly identify important facts in the records, which is impossible if you harbor some prejudice or other. When the relevant facts are missed, it may have a negative impact as regards winning the case or preparing a defense strategy.
Medical review services are a good option for legal teams handling insurance defense litigation and other medical-legal litigation that involves large volume medical records. These services provide great support to paralegals who are assigned the duty of collecting the medical records, categorizing and summarizing them for use during the litigation process.