Medical records summary service is of relevant use to any medical malpractice, disability, workers’ compensation, and personal injury attorney. A well-organized medical record review service organizes medical records in a succinct chronological way to save the law firm’s time in having to do so for any particular case.
Additionally, a medical records summary service can also help in identifying missing records, and issues with the case. In the legal arena, this can help evaluate the advantages and disadvantages of a particular case. The summary service will be valuable if it helps examine specific areas requiring attention and pre-existing states that could have a bearing on a case.
A medical summary is a succinct account of the data filed in a patient’s medical records. Organization and broad research of the medical records like progress notes, physician’s notes, operating room records and consultation notes is prepared to formulate the summary. Data that may be encompassed in this method of a review may include:
* Admission to a hospital along with discharge information
* The cause of the particular accident or injury
* Whatever information was revealed during diagnostic testing
* Immediate and ensuing care given present diagnoses/assessment
* Evidence of negligence on the part of the provider (if any)
* Evidence in support of disability
The medical summaries can be designed in the following formats:
1. Annotative
2. Narrative
3. Analysis report
A skilled assessor of the subject matter who has legal and/or medical education can add worth to a narrative medical summary by conveying a more profound understanding of medical terms and procedures relating to the case.
Here are some of the ways a reviewer gathers information to create a first-class medical summary:
1. Evaluating the entire set of medical records, where each page is vital.
2. Classify the type of the case (Workers Compensation, Social Security, Personal Injury, Medical Malpractice, Slip and Fall or/and Medical Negligence)
3. Provide a short narrative of the history of an accident/injury (textual/abstract summary)
4. Provide the present status of a patient’s health. Like details of current treatment, medications, physical therapy or the extent of disability (if any).
5. A brief of the archives to contemplate the past medical history of the patient in order to assess whether the existing accident/injury has intensified the prior health conditions or injuries.
6. Facts regarding particular test outcomes that were taken over a particular period of time.
7. Categorize the CPT (Clinical Patient Testing) Codes and the ICD (International Classification of Disease) codes.
8. Create a detailed outline of any upcoming treatment or/and related injury.
9. Describe and define medical procedures and terminology.
10. Include commentary regarding the fundamental relationship of diagnoses or/and treatment of the damage.
11. Condense the information and opinion about research analysis.
