Summarizing Medical Records

by | Published on Sep 26, 2013 | Medical Case Summary

When summarizing medical records, it is necessary to ensure that the summary contains all important data contained in the records. Inferences as to what is significant should be based on the major issues involved in the case. The pitfalls in summarizing include missing out on significant pieces of information and including superfluous or unimportant data. Here comes the question of the competence of the medical record reviewer. The reviewer must necessarily have a comprehensive understanding of the various issues pertaining to a case.

The best practice is to begin reviewing only after you have secured all the relevant medical records. This is the best way to understand each and every incident and action. Reading the entire record is crucial to avoid missing out on important details. Any inconsistency should be noted and looked into in detail. A reliable medical summary should contain the following information about the claimant.

  • The claimant’s description of the incident
  • Current condition
  • Medical history
  • Medical provider’s physical examination, evaluation, clinical impression, diagnosis
  • Treatments, surgery, medications etc.
  • How the plaintiff responded to the treatment
  • Any proof of non-compliance
  • Medical provider’s prognosis regarding the probable cause of an injury/disease, the chances of recovery, and the degree of recovery possible
  • Plaintiff’s knowledge of malpractice
  • Any other information that is pertinent to the case.

Medical record summary can be in the narrative or chronological format. In the narrative format, the information from the medical records is extracted, summarized and presented in an easy-to-read layout. In this only data that is crucial to the case is provided; this type of summary is imported as such into trial briefs, arbitration/mediation briefs and demand letters. These can be made more comprehensive according to the requirements of the attorney and the case. In the chronological summary, all important medical events/treatments are listed in chronological sequence. The information can be made detailed or brief as required. When all individual records have been summarized, a limited chronology is prepared. This is useful when drafting demand letters and when preparing for deposition or trial.

Attorneys and paralegals need not burden themselves with the time-consuming task of medical record collection, organization and summarization. A reliable medical record review firm can provide value-added support in this regard via customized medical case history and summary services.

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

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