Monthly Archives: December 2017

What is a medical consultation report and what are the parts to it?

A consultation report is generally ordered from a doctor who has referred another doctor to a patient. The consulting doctor is a specialist in an area that the other doctor doesn’t focus on, therefore needing a second opinion on a patient’s situation. With consultation reports, there is generally a brief history of the patient’s illness/disorder and also an exam if the consultation needs that information. The end of the consultation will cover a strategic plan that the doctor would like to happen in order to solve the patient’s illness. Consultation reports can vary in length, depending on the difficulty of the patient’s case.

Identifying Missing Records

Why You Might Need a Consultation Report

Consultation reports are used to describe the patient’s past history and the reason for being treated with a clear solution as well. The report will let the additional doctor know why the patient is there, in a brief report. Consultation reports are frequent in hospitals, such as an E.R., when one doctor makes the initial assessment and sends the patient to a specialist. Having another person review a case can give a doctor as well as a patient a sense of ease and reassurance. It also opens up opportunities in other areas of the medical field and exploring other treatment options for patients.

Details in a Consultation Report

A consultation report will start by listing some specific information regarding the report and patient such as demographic, the date, and the referring doctors. More basic information such as the date of birth and a patient ID number. Once the brief statement that identifies the reasoning behind the consultation, there will be a detailed summary of the patient’s current issues.

Patient’s Past History

The patient’s history, medical and personal, will be listed so the doctor can review that information as well as help determine the diagnosis. One or more of these sections will be included in this part as well:

● Medical History: State any ongoing and also, past medical conditions and also any surgeries.

● Allergies: Make it known if there are any medications that the patient is allergic too

● Medications: What medications and also the dosage that patient is currently taking.

● Personal history: List if the patient smokes, does drugs or drinks.

At times, this can be vital information to what solutions doctors may have in mind as well as what medications to prescribed, if needed.
Family history: Mention any medical issues that the patient’s family members have or experienced in the past.

The treatment

The treatment section should have alternative solutions. It should be discussed with the referring doctor as well as the patient. A statement of refusal should be included in the report if a treatment has been discussed with a patient and they decline. If treatment has been done, it should be recorded in detail. This includes the time the patient was treated and how long the treatment lasted.

Guide to Reviewing and Summarizing Personal Injury Cases

Medical summaries are valuable to personal injury cases. Generally, medical summaries are prepared by legal nurse consultants so that attorneys can use them during the case. The medical summary will briefly describe parts of the case as well as the accident so that it is easy to locate when there are questions during the case. The records of the patient as well as medications and any other information that is valuable to the case will be found in a medical summary. There are parts to a medical summary that will help a persona injury case. Here are some parts that make up a medical summary.

Personal injury claim

Charts and tables

To enhance medical summaries, you can provide charts and tables that will breakdown medical records as well as any tests to show changes that have been made to a patient. There are rules regarding the layout of this section to a medical summary such as fonts and colors to emphasize certain information. Background colors as well as font colors should compliment each other and not be used to make it hard on the eyes when observing the charts.

Chronological order

One of the main purposes for a medical summary is to have information of a patient be in chronological order. The information being presented in a timeline fashion can be beneficial when a jury or judge is asking questions regarding a timeframe.

Medical sketches

Medical illustrations can be anything from hand drawn pictures, pictures found in textbooks, and any other materials that can be used to accommodate information. Photos that are presented in the medical summary can also be photos of the patient and their personal injury. For example, if there were scars that were caused from the injury, pictures can be taken of these and be used in the medical summary.

When working on your medical summary, just remember that the summary is only part of the evidence in your case. You should have a medical expert examine this summary or work on it so you are providing a quality medical summary for your case. Be sure to include not only past injuries, but also a claim of the effects of the future of your client as well. Any medical charges that are associated with the injury should be included. A high-quality medical summary can go a long way in personal injury claims.

Here’s why having a concise medical summary will benefit your case

Medical Summaries are records that are in chronological order. They are used and said to be the more critical for insurance claim cases. Collecting all medical records can be timely and effect your case, timewise because you have to go through hundreds of papers to identify, review, and summarize records. Though it is a timely task, it will make trials go faster after the summary is complete.

Patient Medical Summary

You will need to provide all of the medical professionals you have seen that is relevant to your claim. This information will start from the beginning when the accident happened and who first responded to your accident. Chances are, your attorney that you are working with will want you to carry out a HIPPA-medical authorization so they can have your records released to them. Medical Summaries are critical to cases and here are 3 reasons why.

3 reasons why you should keep an organized Medical Summary for You Case:

1. Assessing your case: Unfortunately, those medical bills that keep piling up because of your accident will come into play in your claim case. During cases, the judge will want to know how much you have gathered in medical bills and will expect you to answer it quickly. This will generally be asked toward the beginning of your claim by an insurer that is working on your case.

2. Answers for rebuttal: Once your claim is filed, there will be questions based on the information in your medical records. If your medical summary is well-organized with all of your records in order as well as billing information, you will be proving to the defense that you are prepared and they will need to find hard evidence for your to lose your claim.

3. Using information as exhibits to the jury: Like any other case, you generally just have one shot to plead your case and make it count. You can always appeal, but with appropriate information and a concise medical summary, you have provide all the evidence they need. You should be providing the information in a way that the jury will understand, it is easy to translate, and there is no hidden details. You want them to understand how your life has changed since your accident.

One of the ways to maximize your disability benefits and increase your approval for your claim is by conducting a full examination and preparing a medical summary. Compiling reports in full and submitting them to the insurance company. Based on the reasons above, you should be working with a lawyer to help you in your time of need. They can help you during the application process while you’re trying to recover, do their best to increase your benefits and compensate you for the injuries that you have.

How Custom Medical Record Summaries Save Law Firms Time and Money

Nearly two-thirds of client-prepared Social Security Administration (SSA) disability claims are initially denied. Why? Lack of thorough medical evidence. It’s a hard fact. Therefore, clients seek out law offices to handle their disability claim cases. Lawyers often don’t have the time to gather the detailed complete medical records that SSA requires to substantiate and evaluate a medical claim.

Custom Medical Record Summaries

That’s why many law firms around the country hire us. We prepare detailed medical records summaries, dating back as far back as possible, and as comprehensive as possible—including detailed doctor’s notes, medical tests performed and medication history.

Lawyers know it well—your clients hand over a stack of disorganized medical records for you to sort through and turn into something that makes sense. We’ll take that off your hands. Allowing us to create the medical synopsis frees up time for you to work on other important aspects of your cases. Providing this organization requires many hours of your time to transform it into a medical synopsis that makes sense.

Our firm provides a medical chronology report that is thorough and detailed. We summarize the client’s disability and provide a timeline of events. We provide a well-organized, chronological report.

Why do attorneys use our services? There are several reasons:

• A report format that allows attorneys to quickly and easily understand a client’s medical history so that a strategy for filing or appealing can be developed.

• An executive summary that serves as a medical synopsis of the case.

• A list of referenced, indexed documents that ultimately saves the attorney lots of time.

• An easy-to-understand report that is available to every professional in your law firm to help with their particular contribution to the overall case. Single point failures will be a thing of the past—no longer will only one person in your law firm know what’s going on with the case.

• Expertise to validate the disability and provide supporting evidence of the extent of the disability to bolster your case. Our in-house team of experts substantiates both symptoms and treatment.

• Background information, such as diagrams, illustrations, anatomical drawings and medical term definitions.

• Reports using the standard SOAP (Subjective, Objective, Assessment, and Plan) format, widely recognized and used in the court system.

Hiring our firm drastically improves the productivity of your firm. You have more time to focus on the legal aspects while we handle the medical aspects. What lawyer wouldn’t want to free up more time from his or her paralegals and other staff?

In our experience, we’ve found that a professional, custom medical summary can make a difference in whether a disability claim is approved or denied. If the evidence you provide to SSA has any gaps of treatment, or does not directly tie your disability to your inability to work, it will most likely be denied.

SSA is looking for two things: (1) evidence of the extent or severity of the disability, and (2) relation of the medical condition to a person’s inability to work.

Of course, SSA reports are not the only reports we provide. We can tailor a medical report to the attorney’s needs. Our mantra is that we only provide the level of medical detail that corresponds to the report’s purpose. In other words, less is definitely more. We deal with very straightforward reports to very complex reports that involve complicated details. Here are some of the reports we provide:

Medical Chronology

Chronologies are necessary for disability claims (SSA and VA), as well as other cases in litigation, such as workers compensation cases or personal injury lawsuits. Medical providers, medical events and other details are provided:

• Complete medical history

• Disability or condition onset details (dates, symptoms and progression)

• Doctor visit summaries

• Clinical/diagnostic test results

• Prognosis of the condition

• Doctor opinions on future medical care

Brief Medical Summary

This is a summary report that shows key events and medical issues on a timeline, but that doesn’t have lots of detail. Attorneys use these reports for pre-litigation information.

Detailed Medical Summary

This report is a more detailed, chronological summary and contains more discussion about key medical issues. Attorneys use these to initially evaluate a case in litigation or being considered for litigation.

Hire Us

Preparation for your hearing requires an accurate, concise medical summary or report. Instead of writing it yourself, choose our company’s quality work. We are very familiar with SSA’s rules and regulations and tailor our reports to match. We will provide the detailed argument and justification for how your clients are classified as disabled under SSA’s description.

Hire us to do the tedious work. We have a proven track record. Give us a call today.