Documentary evidence is a critical component of all litigious matters. Thinking specifically about retrospective chart reviews, also known as a medical record review, a thorough understanding of the information within medical records can make or break a case. In this month’s INSIGHTS article, we explore medical chart reviews and chronologies and share seven best practices for attorneys and paralegals when reviewing medical records, interpreting the information, and when to engage a medical professional for expert review and analysis.
What is a medical chart review, and what is a chronology?
Medical records include various components and documentation of patient history, clinical findings, diagnostic test results, preoperative care, operation notes, post-operative care, and daily notes of a patient’s progress and medications after an injury or illness.[i] “The medical record frequently is the most important document available in defending against or preventing legal actions, including but not limited to personal injury suits, criminal cases, workers’ compensation actions, disability determinations, and claims of negligent or improper healthcare (medical malpractice), and is generally admissible at a trial.”[ii] A medical record chronology organizes medical records, treatment history, and medication history from the injury or illness date to the present.
When should a medical chart review and chronology be completed?
A medical chart review and chronology is completed either before or after a lawsuit is initiated. Before filing a case, a medical chart review and chronology is a great resource to reveal the story, gain a deeper understanding of the injury or illness, and determine whether liability is attributed to the opposing party. A medical chart review might also be completed after a lawsuit is filed by either the plaintiff or the defense. The complexities and long-term implications of an injury or illness, the necessary treatment, and the attorney’s experience generally inform whether a review and chronology is completed before or after initiating legal action.
To get the most from a medical chart review and chronology, we share seven best practices for reviewing and understanding medical records and the stories they tell.
- Understand the information you’re looking for and how it gets into the chart
A foundational understanding of who adds information to a medical record and how that information is added is paramount to completing a thorough medical chart review. Many health care providers can add information to an individual’s medical chart, including the medical transport team, physicians, nurses, laboratory technicians, physical therapists, and any other health care professional providing care. Consider an automobile accident with 12 months of post-injury treatment; at the very least, records should be reviewed from the accident’s scene or initiation of injury to the present time. In this instance, records include those of the EMT team that assist the scene, emergency room records, in-patient acute hospital records, rehabilitation hospital records, and outpatient care and physician visit records. And each encounter with a professional may include the chief complaint, physical exam, history of present illness, an assessment and plan, lab or radiological orders, prescriptions, progress notes, and test results.
It is also essential to understand how the information gets into the record – is it dictated and transcribed, or handwritten, as the method used for charting can affect the accuracy of the information. According to Air Medical Journal, “…the process of dictation and transcription has been shown to introduce more inaccuracies into the medical record, such as in recording childhood immunizations.”[iii] Electronic health records add yet another layer of complexity and may be confusing for the untrained eye to review and understand.
- Ask Questions
The more questions you ask, the more information to factor into your case, including pre-existing injuries and illnesses, medications, and prior and current treatments. When interviewing your client, ask open-ended questions to learn as much as you can about the patient’s health history. The goal is to uncover any other illnesses or conditions and when they might have begun, medications they are presently taking or may have taken in the past, or any information which may factor into how the individual is healing.