Medical Records in Litigation – Importance of Proper Organization and Analysis

by | Published on Feb 12, 2013 | Medical Record Review

Medical record review is an important process for attorneys involved in medical litigation. In fact, organizing the records is the first step in the process of understanding the case. You have to ensure that all relevant medical records are available. These include admission charts, emergency room records, operative reports, nurses’ notes, progress notes, physicians’ orders, lab reports, imaging reports, discharge summaries and more. Decision making is to be done on the basis of the information available.

Accurate Medical Review – a Big Deal Indeed

Medical chart/record review has to be flawless – this is an indisputable fact. In the legal scenario, the entire case structure is built on this. Since medical issues and terminology are involved, the review process is best handled by a team of knowledgeable professionals comprising medical entities as well as language and documentation experts.

  • The team is important because these professionals can clearly interpret medical jargon for non-medical persons.
  • A well-established medical case chronology will provide a clear timeline of medical encounters.
  • Accurate medical review will help the counsel to understand aspects such as why the services were required, what services were actually provided, whether they were provided in a timely manner, whether the care provided was appropriate, and so on.
  • Concise summaries that give a clear review of the case will help attorneys during all stages of litigation. Expert summaries will provide a clear outline of the patient’s medical history, identify ambiguous factors, errors and tampering of records and also highlight missing information if any.
  • Attorneys can easily evaluate the strengths and weaknesses of the case. The accurate chronology, history and summary provided will help them avoid wasting a lot of time chasing a hopeless case.
  • What is most important about a professional medical record review team is that they provide legal professionals with an objective documentation of the information as found in the patient chart.

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