Medical records summary service is of pertinent use to Personal Injury and Medical Malpractice law firms. A well prepared medical record summary service save times by organizing medical records in a concise chronological manner facilitating easy assimilation. It can also help in determining whether a patient is being provided proper treatment for his/her ailment. In the legal field, it can help assess the merits and demerits of a case. The summary service would be useful if it helps scrutinize deviations or negligence from the standards of care, questionable happenings, particular areas requiring attention and pre-existing states that could have a bearing on the case.
What goes into a medical summary?
A medical summary is a concise version of the information found in a patient’s medical records. Arrangement and extensive research of the medical records such as progress notes, consultation notes, physician’s notes, and operating room records is done to prepare the summary. Information that may be included in this form of a summary includes: the cause of injury or accident, entry into and discharge from the hospital, immediate and ensuing care given, what diagnostic testing revealed, present diagnoses/assessment, medical expenditure and negligence on the part of the provider, of any.
Types of medical summaries:
Medical summaries (or medical chronologies) can be:
1. Annotative
2. narrative or
3. analysis report
A subject matter expert reviewer with medical education can add value to a narrative medical summary by bringing in deeper understanding of medical terminologies and procedures pertaining to the case at hand.
Salient Features of a medical summary report:
Accurate data capture from handwritten text.
1. Chronological arranging of patient data and highlighting important medical information.
2. Helps to determine if there was negligence or deviation from the standards of care
3. Identify areas of concern and questionable occurrences
4. Spot any pre-existing conditions that may affect the case
What goes into the good medical summary report?
i. Emergency room visit and Hospital stay
ii. Patient’s personal information
iii. Entry into and discharge from the hospital
iv. Immediate and ensuing care given
v. Medications provided and those in use
vi. Information concerning the injury or illness
vii. Opinions of medical professionals with regard to causation, appointment, and disability
viii.Diagnostic test results.
ix. Surgical reports.
x. Physical therapy, Occupational therapy,
speech-language therapy reports.
xi. Independent Medical Evaluation Reports
(IME).
xii. Medical citations where applicable
Recommended tips for a reviewer:
Here are some recommended practices for a reviewer to produce a high quality medical summary:
1. Review the entire set of medical records, where every page is important.
2. Identify the nature of the case (Personal Injury, Slip and Fall, Workers Compensation, Social Security, Medical Malpractice and/or Medical Negligence)
3. Give a brief description of the history of injury/accident. (abstract/textual summary)
4. Give the current status of the patient’s health. (Whether under any treatment, physical therapy or medications, extent of disability, if any etc.)
5. Summary of the records taking into consideration the past medical history of the patient to assess whether the present injury/accident has aggravated the previous injuries or health conditions.
6. Details of specific test results, taken over a period of time.
7. Identify the ICD (International Classification of Disease) codes and the CPT (Clinical Patient Testing) Codes.
8. Outline of future treatment and/or related impairment.
9. Explain and define medical terminology and medical procedures.
10. Add commentary on the causal relationship of diagnoses and/ or treatment to the loss.
11. Summarize the report and opinion relative to research analysis.
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