Read the blog to have an understanding about medical summaries and tips to consider while summarizing medical records.
Medical summaries are an easy reference tool for attorneys dealing with cases related to medical emergencies like personal injury, medical events arising out of medical negligence or malpractice, product liability, social security disability and ambiguities in medical insurance claims. For example, attorneys and paralegals working on such cases need to review the medical records of the plaintiff to identify comprehensive details about the following:
- the date of occurrence of the injury
- details of the patient
- the treatment or services offered by the healthcare practitioners immediately at the scene of the of the event or in the emergency room
- nature of the injury with specific details about the location of the injury that highlights the severity of the injury
- Duration of the patient’s stay at the hospital
- Diagnostic test results like X-Ray, CT Scan, and MRI Scan
- Prescriptions from the physicians or referrals, if any
- Details about the treatment providers and the exact dates of services or treatment offered
- Assessment of permanent impairment if any
- Remarks issued by the physician
- Medical terms or phrases used
How Important Is Medical Summary for Attorneys to Evaluate a Case?
- Summarizing pertinent medical records chronologically has a vital role in defining the course of a case during both pre-litigation phase and trial phase.
- Providing fair medical review to the law firm has penultimate significance during the trial phase.
- Regardless of the attorney on the plaintiff or defense side, he/she has to juggle a mounting number of civil litigations related to medical events on a daily basis but flawless medical summaries prepared by an expert panel of medical professionals and legal nurse consultants can ease the task.
- The summary of medical records comprises relevant information regarding the ailment, diagnosis and medical opinion which will help the attorney prove liability by demonstrating the damage inflicted upon the patient by the medical negligence or malpractice and by establishing the causation.
- A powerful medical summary is compelling, and is a narrative representation of the client’s treatment information, which ensures that the case doesn’t get derailed.
Types of Summaries
A medical summary can be written briefly or elaborately based on the requirements of the attorney.
For pre-litigation review, the medical summary is brief and devoid of intricate details. It summarizes the crucial events of the medical history in a narrative format that are critical to the case.
All the relevant information is written chronologically in a detailed medical summary and the report typically comprises 2 to 10 pages. Detailed summaries are often preferred by attorneys to evaluate comprehensively every facet of the litigation filed wherein important facts are highlighted.
Keeping track of the voluminous medical records in an organized manner is the foremost step to efficiently summarize it.
Important Tips to Summarize Medical Records
- Reviewing the plaintiff’s allegations
Prior to preparing the medical summary, it is very important to be aware about the allegations raised by the plaintiff as it could help legal nurse consultants to list the facts effectively so that attorneys can refer the details easily without investing time for cross-verification.
- Effective introduction to highlight the context
It is an inevitable part of a medical summary as it should give a concise briefing of important facts. The introduction should not be stuffed with medical terms as this would make it difficult for attorneys to completely comprehend the case. Introduction helps to have a glimpse of the medical records reviewed.
- Identifying medical providers
It is a part of extracting relevant records about medical and billing details as it is a major part of evidence exhibit. The plaintiff might have received treatment from different sources which he/she may not be able to recall. The details about health insurance providers, primary care providers and pharmacy will be intact in the actual records. But the information about additional providers has to be collected from pharmacy records. By accessing pharmacy records through corporate office, prescriptions along with details of physicians who prescribed can be collected.
- Meticulous sorting of medical records chronologically
Medical summary involves listing of timelines of all the medical events encountered by the plaintiff. The details about medical history, remarks of the physicians, pre- and post-operative care, and medications administered have to be organized perfectly to avoid missed information or confusion for attorneys. For this purpose, creating a control log of medical records where relevant information is stored will help to organize the requests and it can be made accessible to the attorneys whenever they need the records for scrutinizing.
- Expand medical abbreviations and decipher physician’s prescriptions
Attorneys or paralegal professionals may not be well-versed with medical terminologies used in the medical summary. Medical summaries are written specifically for people having insufficient knowledge about the treatment strategy, medical terms and repercussions experienced after certain medications or treatment. So, it is essential to describe and expand the medical abbreviations wherever they are used. Similarly, physicians’ notes specifying remarks or prescriptions have to be converted to readable form.
- Focus on readability
Choosing a readable font like Calibri, Verdana, Ariel or Times New Roman with a font size of 10 or 12 will be optimum to increase the readability of the medical summary. Incorporate tables and charts which conform to the principles of desktop publishing. The rules of layout have to be complied with while inserting illustrations and a consistent font has to be used. To enhance the persuasiveness, the exhibit can be given suitable color (Black letters on yellow background is frequently used). Also, breaking up the paragraphs with headings and proper spacing is paramount to understand the content.
- Bates labeling for timely data retrieval
There can be numerous documents associated with a particular medical event and digital technology like Bates labeling can ease the task of accessing the records. Bates numbering is an electronic numbering system used to identify medical documents stored in an automated database system. This is particularly beneficial when some medical records are obtained at a later date. If each document is Bates stamped, it can be easily retrieved as and when required.
- Specify the references used
A medical summary is prepared with the help of reference from various sources like journals and research papers. It is important to cite the source so that attorneys can refer back to correctly interpret the summary.
Summarizing medical records plays a pivotal role in helping the attorneys analyze and evaluate the cases related to personal injuries, and identify treatment inconsistencies based on clinical history and claims.
