A medical chronology provides a brief, accurate, and informative summary of a patient’s treatment history. Attorneys handling multiple cases rely on these reports to understand the key facts relevant to litigation. They gain a clear view of what happened to the plaintiff—the nature and extent of the injury or illness, the care provided, and how the condition relates to the accident or incident. A well-prepared timeline from a professional records review service saves them valuable time spent sifting through large volumes of documentation. Such reports are also valuable for insurers, as they can help in evaluating claims and negotiating settlements before a lawsuit is filed. If settlement is not reached, the patient record timeline serves as an important resource when preparing for depositions or trial.
What to Include in a Medical Case Chronology
If you are developing a legal case chronology or a medical chronology, there are certain components that should be necessarily included.
- Date of injury (DOI) and cause of the injury
- Date of admission and time of admission
- Name of the healthcare provider(s)/facility(ies)
- Medical history
- Diagnostic testing, diagnosis, and imaging results
- All relevant medical encounters and treatment – treatment providers and dates of treatment
- Treatment plan that includes diagnostic details, prescriptions, and referrals
- Hospital visit/stay records as well as those of subsequent treatment by physicians/physical therapists
- Prognosis (possibility of recovery)
- Permanent disability (if any)
- Future medical treatment necessary (if any)
It is best to include even minor details in the medical chronology report. Seemingly minor details and disputed information also may be useful when preparing the case strategy to prove liability, causation, and damages. Missing records or data must also be highlighted in case that may prove useful at a later stage. If any non-medical information that is relevant is found in the records, it must be included in the report because it could help prove causation.
Medical Case Chronology Preparation – Points to Note
- Start preparing the chronology immediately: Facts are crucial to a legal or medical case chronology. Therefore, to ensure that even minor facts are not lost, you have to start writing the chronology report immediately. Any delay could result in loss of information.
- Medical record retrieval: Once the required medical records are identified, the respective medical record custodians have to be identified so that the medical record release request can be sent to them.
- Medical record organization and review: The medical records are sorted and categorized to facilitate their review.
- Medical case chronology and summary preparation: An easy-to-understand report that highlights all important aspects in the plaintiff’s medical chart is prepared. The following points may be noted to ensure maximum value for the chronology:
- Critical areas of the summary may be highlighted
- Delete all duplicate records and create a log of the deleted records
- Prepare the chronology in WORD or PDF format. Hyperlinks can be included for quick navigation to the source records. medical terms can be defined, if required.
A well-prepared medical record chronology is a time-, cost-, and labor-saving tool for attorneys, often helping to resolve matters quickly or serve as evidence at trial. Rather than preparing these reports in-house, attorneys, insurers, and arbitrators can rely on professional medical record review services to obtain accurate, timely, and easy-to-use summaries. Since most legal staff are not trained in healthcare, a professionally created case chronologies offer a clear, fact-based interpretation of events. Complex terminology is simplified, and all abbreviations are expanded for better understanding.
