How Is Meaningful Medical Information Extracted from the Medical Chart?

In any personal injury case, the plaintiff’s medical chart is one of the most important considerations. The information regarding the alleged injury, its extent, and impact are obtained from the medical chart through a comprehensive medical record review. A personal injury attorney relies heavily on such information extracted from the medical records to develop the case. Apart from establishing the basic elements of a personal injury claim, a complete set of well-reviewed medical records helps evaluate the potential strengths and weaknesses of a case. The information obtained from the medical chart also helps to determine how much the plaintiff’s claim may be worth for purposes of settlement. Accurate medical records enable attorneys to prove or disprove causation. In a personal injury case, the plaintiff has to prove that the injury was caused by the negligence of another party. That is why objective evidence presented by the medical records, which is difficult to disprove, becomes very important in such cases.

So, how is this very important information abstracted or extracted from the voluminous medical records? Here are the different steps involved.

* Medical record request and retrieval: This is the first step in the medical chart review process. The records have to be obtained from diverse sources including hospital and office databases, and are usually provided in diverse formats including electronic as well as paper records.
* Medical record organization and categorization: This is a very important process which enables medical record reviewers to identify the records that may be missing, discrepancies present in the records, and special records that may be needed such as CT scans and X-rays.
* Reviewing the data: In this step, the data available is interpreted and analyzed to determine the most relevant information needed in the case.
* Developing medical case chronology: Timelines are very important when it comes to specifying the date of injury and treatments provided. It helps prove that the injury is not consequent to a pre-existing condition, and also that ongoing treatment may be necessary.
* Medical case summary preparation: These summaries break down the medical records, define complex medical terms, review and summarize notes made by physicians and nurses, make all abbreviations clear and easily comprehensible to people with a non-medical background, and give details regarding causation, the various providers, treatment dates, and the patient’s prognosis.

When the medical records are organized, it becomes easier for the attorney to prove the nature and extent of the plaintiff’s injuries, keep track of the treatment provided, as well as document the potential for medical care in the future. The valuable medical evidence extracted from the medical records enable attorneys to prove damages and causation that are very important to a successful personal injury case. In-house review of medical records could be challenging for paralegals and document reviewers without a medical background. A practical way of simplifying the medical record review process and get the required accurate information is to partner with a reliable medical review company. There, the reviewers have a professional background and extensive knowledge of the healthcare industry along with many years of experience in doing such reviews. They will make sure that all medical records are made available, and organized properly. They ensure that no information goes missing and there is no confusion or ambiguity for attorneys handling the case. An experienced company provides legal medical record review with concise and accurate medical record summaries that makes it easier for attorneys to appraise the relevant medical data.

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