How to Write a Medical Chronology

by | Published on Feb 17, 2023 | Medical Chronology

A medical chronology comprises a report that gives you a brief, accurate, and informative summary of a patient’s medical treatment. Attorneys handling multiple cases need this chronology to understand the medical facts pertinent to the case. They can get a clear idea of what actually happened to the plaintiff, the injury/illness and its extent, the treatment provided, and how the injuries relate to the particular accident or incident. A good chronology prepared by a medical records services provider helps them avoid the need to sift through vast volumes of medical records. Medical chronologies are valuable tools for insurers also because it can assist them in working out the settlement of a claim before a lawsuit is filed. If a settlement is not reached, the medical/legal case chronology can be used to prepare for a deposition 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 case chronology is a time-, cost- and labor-saving tool for the attorney, and it may help settle cases or be used at trial. Instead of having the chronology prepared in-house, attorneys, insurers, and arbitrators can utilize medical records services to obtain accurate, timely, and useful medical chronologies. Attorneys and insurers and their office staff are typically non-medical personnel and therefore a professionally prepared medical case chronology would be easy to read and understand. It would be a clear interpretation of the medical events based on solid facts. Complex medical terminology will be explained and all abbreviations expanded.

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