Easing the Burden of Summarizing Medical Records with Medical Review Services

Medical records review and summarizing the information found in those records is an important task for any attorney handling medical litigation. This often involves countless hours and a lot of effort at comprehending the complex medical terminology. In a law office, paralegals may assist the attorney with the review and summarization tasks. However, a better time and effort saving option is always available in the form of medical review services provided by medical record review companies. Accurately summarizing medical records is critical to the outcome of the case. Here is what the record review and summarization process involves.

Organizing and Summarizing Medical Records

In a personal injury or mass tort case, there may be multiple medical providers and numerous medical records, and only a thorough review will reveal the extent of the claimant’s injuries and treatment plan. The first step is organizing and preparing medical case summaries as and when each document is received. Other processes include:

• The records received from each provider are separately grouped.
• Medical records are categorized as
• Progress notes
• Nursing notes
• MRIs, X-rays, radiology reports
• Prescriptions and referrals
• Chronological arrangement of the records with the most recent at the top.
• Table of contents for the medical records index.

Charting an Accurate Timeline

It is important that the attorney has for ready reference a timeline of the sequence of events in the hospital, represented by means of graphs, charts etc. The time from the patient’s chart is charted right from the beginning, and would include all details such as when the medicine was given, when procedures were done, when MRIs, X-rays, scans etc. were performed. A comprehensive timeline would clearly account for each and every minute the patient spent in the hospital/healthcare facility receiving treatment.

An effective medical case summary would incorporate both text and graphics to convey all relevant details clearly to the judges, jurors and mediators. Tables and charts enhance medical summaries and increase their effectiveness. The main intention behind summarizing medical records is to allow the attorney to locate a piece of information quickly.

Medical Record Summary – a Powerful Litigation Tool

Medical summaries prepared as part of medical record review for attorneys are great litigation tools that help in the resolution of personal injury, medical malpractice and mass tort cases. The fact-based chronologies and summaries would clearly present the important information contained in the medical records. These are delivered in the client’s preferred format.

• The summary would clearly describe the injury/accident, the mechanism of injury and the immediate care provided both at the scene of the accident and the emergency room.
• It would contain details of hospital stay and information regarding treating physicians and results of diagnostic testing.
• The comments of the treating physicians as regards the causation of the injuries, diagnosis, and permanency will be included.
• Details of medical expenses may be included.
• Typically, information regarding missing records, problematic medical concerns and red flags is provided in a separate letter to the attorney.

Now, with technological advancements, there is web-based software that can be used to summarize the medical records retrieved from various sources. This speeds up the record review and summarization process and saves review professionals valuable time and effort spent hunting for vital information that lies deeply embedded within medical records. A medical record retrieval company offering services to insurance and legal professionals provide the use of such innovative software to their clients. This has a user-friendly platform and offers tools that help in efficient and comprehensive review. Clients can quickly locate the pertinent information, summarize it in their own words, and generate that information in an organized format.

Managed Outsource Solutions (Mos) has providing value-added medical record review services for the medico-legal industries.