Compensation Claims & Role of Medical Records Summary for Attorney Review
By Joanna Hawkins
Medical records summaries provide attorneys and others involved in medical-legal cases or claims settlement cases with a summary of the individual's medical state. The fact-based report, which is based on a systematic chart analysis, includes details on existing illnesses, work-related injuries, and all similar medical conditions. The medical record review and analysis process includes several steps, including gathering and organizing patient reports, consultation of healthcare services, recognizing factors that contribute to alleged incidents or injuries, summarizing written reports, evaluating and comparing witness accounts, and making a chronology of events.
To help lawyers better understand the nature and cause of injuries and how they affect a particular case, legal nurse consultants (LNCs) utilize the nursing process to assess relevant, complex cases. They also participate in client interviews and case strategy discussions as needed. Key features of medical summaries written by LNCs include an introduction that describes the case while highlighting important details; skilled formatting to make the content easy to understand; writing using easily understood language for individuals who are not medical professionals; and recommendations on the kinds of expert witnesses required, other witnesses who should be questioned, and other details.
The review may be short — just 1-2 pages including only highlights of relevant activities and concerns — or longer, with 2-10 pages and a chronological listing of all the relevant information. The shorter reports may be for initial pre-litigation analysis or for a case the lawyer will reject, while the longer summary may be used for an initial assessment of case prosecuted or one the lawyer might consider taking.
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