Preparing a Medical Records Summary for Attorney Review

by | Jan 27, 2016 | Medical Record Review

Preparing a flawless paralegal medical records summary for your attorney requires years of experience. The important thing is to be well-versed in the vocabulary of medical legal technology and also understand the nuances of civil litigation. Often, with a few days left before trial, paralegals at say, an insurance defense firm, may find themselves face to face with an intimidating stack of medical records that are to be reviewed before a medical case chronology and summary report can be created. The challenge is that paralegals with little training in medical terminology, treatment procedures and other relevant aspects may have to identify and report important details such as pre-existing conditions and treatment gaps. Any injury claim requires the preparation of a chronological medical summary that will help to understand the nature of the injury, the patient’s past medical history and its impact on the injury and other vital information. An attorney can evaluate a claim only after completely understanding the injury and its relationship to the incident in question. Paralegals have the option of utilizing affordable medical record review services that will help submit timely medical records summary reports for attorney review. This summary is significant in that it will be used for discovery and investigation, for preparing for the trial, for reporting to the claims adjuster, and for exhibits and witnesses.

What are the important elements of a medical records summary in an insurance defense case?

  • Date of Injury or DOI: This is a critical element in the summary. The attorney may need information regarding one specific injury only. But the paralegal must highlight all injuries that are related to that particular injury. The DOI helps distinguish one injury from another in a plaintiff’s medical chart.
  • Causation of the injury or illness as reported by the patient
  • Diagnosis or diagnoses
  • Treatment Providers and Dates of Treatment: Information regarding the various providers and the dates on which the services were provided is crucial in a personal injury case. This information will be used throughout the court proceedings.
  • Treatment plan (s) which would include diagnostic reports, prescriptions and referrals
  • Prognosis or the likelihood of recovery
  • Permanent impairment, if any
  • Future medical needs, if any
  • Information about prior as well as unrelated medical treatment, if any
  • Deciphering and summarizing physicians’ and nurses’ notes and handwriting. The paralegal must be familiar with common medical abbreviations. The abbreviations can be used in a summary if everyone using the medical summary is familiar with them; if people unfamiliar with such abbreviations will be using the summary, then the full form of the word or phrase should be provided.
  • Definition of medical terms can be included in a medical summary for quick reference.

Medical record review for attorneys is a very important task that paralegals are entrusted with. The medical summary created will help the attorney understand the various aspects of the case and find the information she/he is looking for quickly. A good medical case summary can be critical to the outcome of a case.

To learn more about Medical Records Summary we have written a new blog “What Is a Medical Records Summary and How Is It Useful for Attorneys?” on August 16, 2017

Discover our medical record review solutions and partner with us for your next case.

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