A medical chart review is indispensable with regard to processing health insurance claims and to understand the nature and extent of injury or illness sustained by a claimant in a lawsuit. The claimant’s or plaintiff’s medical records are gathered and analyzed in detail. These records include hospitalization records, lab results, and medical history reports among others. In a medical-legal case, both the plaintiff and defense attorneys may have to perform medical record reviews to understand various medical facts and find evidence to support or defend their clients.
Before going on to the types of lawsuits that need medical chart review services, let us look at what this process involves.
- Requesting the relevant medical records from various healthcare practices and facilities
- Medical record organization, and categorization
- Interpreting the records
- Medical case chronology preparation or creating accurate medical timelines
- Preparation of medical case summaries
What are the various types of medical records the attorney has to collect?
- Admission records
- History and physicals
- Progress notes
- Consultation records
- Physicians’ orders
- Lab reports
- Diagnostic reports
- Anesthesia records
- Surgery or operative reports
- Nursing notes
- Nursing discharge instructions
- Discharge summary
- Attestation (a summary of the patient’s diagnoses without using medical abbreviations, and including the treating physician’s signature.)
Here are the different types of lawsuits that require medical records services and a comprehensive medical record analysis.
- Personal injury cases: The medical case chronology created through the review helps prove the injury sustained and understand the medical encounters in a chronological manner. The review also helps rule out any pre-existing conditions.
- Medical malpractice or negligence cases: Here also, review of the medical records is vital to evaluate the strengths and weaknesses of the case as well as its potential value. Also, it helps establish whether there is an element of malpractice involved.
- Social security disability claims: If a social security disability claim is denied, the attorney would use the evidence provided by the medical record review to argue the case.
- Product liability case: Here, the review helps prove whether a plaintiff suffered an injury or harm due to the use of a defective product. The medical records can clearly show the injured person’s health condition before and after using the alleged defective product, and this helps determine whether the product caused the patient’s injuries.
- Mass torts: In mass tort cases, medical records review helps understand the complexities of such cases, identifying proof of use, proof of injury, and any conditions that may delay or prevent recovery.
- Workers’ compensation claims: In these claims, a clear chronology and comprehensive medical records analysis are vital to prove whether an injury is work-related, and thereby covered under workers’ compensation. The medical record review would also show whether the worker has pre-existing conditions or injuries before filing the claim, which could contribute to the degree of harm caused.
Medical records contain important information about the plaintiff’s diagnosis, prescribed drugs, medical and social history, review done by professionals, lab test results and so on. Medical chart review enables the attorney to ascertain whether the defendant is liable for the damages caused, and the nature and extent of the damages. With a reliable medical case summary, attorneys benefit from a clear and chronological understanding of the various medical records related to all major as well as minor medical events in that period.
