What Are the Core Medical Records to Review in Medical Litigation?
In any personal injury case, the study of medical-legal issues involved can be challenging and comprehensive, and would require detailed reading and skilful interpretation of the various facts. The purpose of medical record review for attorneys is to provide the attorney with a clear understanding of the facts specific to the case so that he/she can analyze the case in tandem with the existing statutory and case law involving standard of proof of medical causation, jurisdictional issues and compensability issues. Any medical records review include the organization, summarization and analysis of medical records by a medical review team comprising people with a sound knowledge of medicine and experienced in interpreting the medical data. A good review team would include physicians, registered nurses, legal nurse consultants, professionals from a medical background and documentation specialists. Medical Records Review -- Core Areas of the Medical Chart Whatever the type of medical-related case or its circumstances, there are certain important areas of the medical chart that must be surely reviewed. It is from these parts of the record that the attorney can obtain important pieces of information about the care provided to the patient and what did or did not occur during the treatment period. A comprehensive review of medical records is to be done in any medical-legal case whether for the plaintiff or defense. The following are the crucial areas to review. Physicians’ orders: These are to be carefully reviewed to find out whether the orders were carried out by the nurses and other clinical staff in a timely manner. Their relevance to the patient’s diagnosis must also be considered. Lab reports: Lab results need to be reviewed and interpreted to learn about the diagnosis of the patients. It is to be determined whether there are any abnormal results that the physician may have overlooked and thereby left some health condition undiagnosed.
Progress notes: These records are important because they provide a timeline regarding the patient’s condition from admission to discharge. They give a clear perspective on the physicians’/nurses’ evaluation of the patient and contain valuable information regarding the patient’s response to treatment and care. H&P report (History and Physical): This report is prepared after the first evaluation of the patient. In this, the physician notes down details about the signs and symptoms he/she observed, and the initial impression and diagnosis. H&P helps in evaluating the physician’s services and determining whether the prescribed treatment was appropriate. Prior medical history of the patient is a valuable tool for alerting the physician about what must be done or avoided in the treatment plan.
Medication report: Medications are administered by the nurses in attendance and are recorded in the medical record. This report provides information on the type of medication given, the time and route of administration as well as the dosage. These details will help identify any error or delay in treatment. The medication report must be compared with the physicians’ orders.
Medical Review Solutions for a Clear Understanding of the Case Let me conclude this article with a brief mention of what medical review solutions generally comprise.
Organize the medical records and other medically related litigation material Medical case chronology preparation (for medical events and timelines) Initial case screenings for merit and causation Analyze the records to identify standards of care, type and nature of injury and its impact Identify and apply multidisciplinary standards of care and regulatory requirements
Medical case summary preparation to help attorneys understand the various medical facts and other issues relevant to the case.
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