Preparing Medical Chronologies -Tips for Reviewing Medical Records

Preparing a flawless paralegal medical records chronology or summary for your attorney can require years of experience. The important thing is to be well-versed in legal and medical terms  and also understand the nuances of civil litigation. Often, with a few days left before trial, paralegals at a personal injury law firm may find themselves face to face with an intimidating stack of medical records that are to be reviewed for preparing a medical case chronology and summary report can be created. 

Medical chronologies are appropriate reports for most types of medical legal cases.  Non-medical lay-people aren't used to flipping through charts to find the pertinent information related to a patient's case or claim.  A medical chronology solves this problem by listing all pertinent information in chronological order making it easier for all involved to understand the patients injury, treatment, and possible future medical issues.  Additionally, a medical chronology identifies critical information such as the provider and type of record.   

The challenge is that paralegals with little training in medical terminology, treatment procedures, and other relevant aspects of the records may have to identify and report important details such as pre-existing conditions and treatment gaps. Any injury claim requires the preparation of a chronological medical summary that will help those in the case to understand the nature of the injury, the patient’s past medical history and its impact on the injury, and other vital information. 

An attorney can evaluate a claim only after completely understanding the injury and its relationship to the incident in question. Paralegals have the option of utilizing medical record review services that will help submit timely medical records summary reports for attorney review, but more often than not a paralegal will do the bulk of the medical chronology, if not all of it. 

The medical chronology plays a significant role in any claim or case. It is significant in that it will be used for discovery and investigation, for preparing for the trial, for reporting to the claims adjuster, and for preparation of exhibits and used as reference when examining witnesses.
What are the important elements of a medical records chronology in litigation such as a personal injury? i have created a list of items of significance to note when reviewing medical records. 
  • Date of Injury or DOI: This is a critical element in the summary. The attorney may need information regarding one specific injury only. But the paralegal must highlight all injuries that are related to that particular injury. The DOI helps distinguish one injury from another in a plaintiff’s medical chart.
  • Causation of the injury or illness as reported by the patient
  • Diagnosis or diagnoses
  • Treatment Providers and Dates of Treatment: Information regarding the various providers and the dates on which the services were provided is crucial in a personal injury case. This information will be used throughout the court proceedings.
  • Treatment plan (s) which would include diagnostic reports, prescriptions and referrals
  • Prognosis or the likelihood of recovery
  • Permanent impairment, if any
  • Future medical needs, if any
  • Information about prior as well as unrelated medical treatment, if any
  • Deciphering and summarizing physicians’ and nurses’ notes and handwriting. The paralegal must be familiar with common medical abbreviations. The abbreviations can be used in a summary if everyone using the medical summary is familiar with them; if people unfamiliar with such abbreviations will be using the summary, then the full form of the word or phrase should be provided.
  • Definition of medical terms can be included in a medical summary for quick reference.
Medical record review for litigation or insurance claims is a very important task that paralegals are entrusted to perform. The medical summary will help the attorney understand the various aspects of the case and find the information she/he is looking for quickly. A good medical chronology or summary can be critical to the outcome of the case or claim for your client.

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