Physicians’ Office Records – Ensure You Have the Complete Set

by | Published on Aug 27, 2014 | Medical Review Services

Personal injury cases are mostly settled out of court and this is mainly done on the basis of medical reports. This calls for comprehensiveness and completeness of these documents. In an injury case, the attorney may request reports from the attending physician as well as the examining physician. The physician’s report includes clinical findings, complete medical history of the patient, diagnosis, and treatment prescribed.

Attorneys often rely on a dependable medical review service to organize the patient records in order to prepare a medical summary or when the documents have to be sent to an expert. The important thing is that the documentation must be complete. Sometimes physicians’ offices may not release all the relevant records. A legal professional may not be able to easily identify what is missing. Therefore it is always useful to know the types of physician office records.

  • The intake form is one the patient has to fill out providing information regarding social history, family history, lifestyle habits, current medications, allergies, previous hospitalizations/surgeries, medical conditions, prior illnesses and other relevant details.
  • History and physical notes that include details of the history and physical exam carried out by the physician the first time the patient is being seen.
  • Summary of problems is a consolidated summary of the patient’s medications, vaccinations, chronic illnesses/conditions, allergies and so on.
  • Hospital records include history and physical notes, operative notes, consultation notes from other physicians, and discharge summaries
  • Home care records are reports from the organization providing home care to the patient under the direction of the physician’s office. These include plan of care notes and discharge summaries.
  • Office notes may include dictated and transcribed notes containing data such as weight of the patient, blood pressure, pulse, complaints, findings and diagnoses, treatment and plan of care. This would also contain information regarding the prescriptions and advice regarding follow-up visits.
  • Lab reports, radiology reports, EKG and other medical procedure notes are also important documents in this regard.
  • Correspondence notes include letters sent to and from physicians, consultation notes with other physicians, outpatient services and letters received from the patient and those sent to him/her.

In addition to the above physicians’ office records include billing records, phone call records, disability records, prescriptions and so on. All of these are needed to have a clear understanding and review of the case and prepare accordingly.

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