Top Dos and Don’ts for Medical Records Summarization

In medico-legal cases such as medical malpractice/negligence, mass tort, or personal injury, medical records summarization allows attorneys to extract the plaintiff’s relevant medical information. If there is any error or pitfall in the documentation of the medical records, it can hamper the legal preparation of the trial. In addition, inaccurate information is a loophole and can have serious legal implications. Therefore, a medical records review company has to be relied upon to preserve pertinent patient data and save attorneys from reading through the medical records.

What are the Dos and Don’ts for Medical Records Summarization?

While summarizing medical records, you need to ensure that the medical records are complete, correct, and convenient.

Have a Glance at the Do

• Highlight the most recent information first
  Make sure that you have all the required medical records prior to writing summaries. The medical summaries should reflect the treatment and care received by the patient. It should also elaborately mention the present medical condition of the plaintiff.
• Details of the medication administered
  Ensure that the details of the medication that induced allergic reaction or any adverse condition are mentioned in the medical summary of the plaintiff.
• Focus on clinically relevant information
  It is crucial to list all the health practitioners involved in the treatment of the plaintiff. In a personal injury case, the medical summary should contain the particulars of the medical practitioners who gave immediate care in the ER. Also, the data should corroborate evidence to sue medical practitioners if they have administered the wrong medication to the plaintiff.
• Record the rationale for clinical decisions
  The diagnostic and treatment rationale has to be documented to point out that another course was overlooked. Note down if there was any lapse in obtaining the written recommendation of a consultant. The medical summary should include alternatives considered, the medical judgment of the health practitioner, and the clinical basis of the decision. For instance, care during labor and the rationale for an operative delivery have to be mentioned.
• Mention clinically-related correspondence
  Gather and compile all clinical communication between the health care providers and the patient. For example, termination of a patient-clinician relationship has to be specified in the summary along with correspondence related to the plaintiff’s request or medical practitioner’s decision to terminate the relationship. Also, note any correspondence regarding patient complaints and responses.
• Reviewing to identify conflicting data
  There can be some clinical observations that might impact the outcome of the case. It has to be identified by rereading the notes and factually giving the rationale by consulting with the care providers.

Have a Look at the Don’ts

• Avoid discriminatory remarks
• Include socio-economic details only if it is deemed necessary.
• Never write self-serving or finger-pointing statements in the medical record of the patient.
• Avoid including non-patient care information like details of incident reports or referrals to legal services.
• Altering a patient’s medical record is a criminal offense. Therefore, the medical records have to be maintained intact.
• Avoid using shorthand or abbreviations that aren’t widely accepted.
• The comments and responses of the patient have to be given inside quotation marks.
• Ensure that the medical records do not have imprecise information.

Why Outsource Medical Chart Review?

Attorneys are required to do a thorough medical chart review prior to the summarization of medical records. However, outsourcing the process of medical records review can save time and effort for attorneys. They can benefit from accurate medical case summaries that provide a clear understanding of the case.