Medical Chronology or Summary

Preparing a perfect medical records chronology or summary for an attorney requires years of experience.  The person who prepares the chronology has to be well-versed in legal and medical terms.  We will have a huge stack of medical records that are to be reviewed for preparing a medical chronology and summary report just before few days to trial or mediation.

Medical chronologies or summary report is essential to solve most types of medico-legal cases.  A lay person is not used to reviewing medical charts or records to find the pertinent information related to a patient’s case or claim.  A medical chronology solves this problem by listing all pertinent information in chronological order making it easier for all involved to understand the patient’s injury, treatment, and possible future medical condition.

A medical record reviewer with little training in medical terminology, treatment procedures, and other relevant aspects of the records may have to identify and report important details such as pre-existing conditions and treatment gaps.  A chronological medical summary will help people involved in the case to understand the nature of the injury, the patient’s past medical history and its impact on the injury, and other vital information.  It helps attorneys in evaluating a claim or case.  It will be used for discovery and investigation, preparing for the trial, preparing demand letters and exhibits and examining witnesses.

Fundamentals of a medical records chronology?

Date of Injury or DOI:  The date of injury helps differentiate one injury from another in plaintiff’s medical records.

Causation of the Injury:  The plaintiff may be injured but it is also important to prove that the defendant is the one that caused the injuries.

Diagnoses:  The diagnoses help attorneys properly assess the case.

Treatment Providers and Dates of Treatment:  Information regarding the various providers and the dates on which the services were provided is crucial.  This information will be used throughout the court proceedings.

Treatment Plan:  This includes diagnostic reports, prescriptions and referrals.

Prognosis:  Medical expert examines the plaintiff whose symptoms are continuing, the expert will give a prognosis for future recovery.

Permanent Impairment:  Disability is a result of impairment, but impairment does not always result in disability. It is also important to note that impairment can be permanent or temporary, and there is also permanent and temporary disability.

Future Medical Expenses:  Special damages that may be awarded as part of plaintiff’s total recovery.

Information about prior as well as unrelated medical treatment.

The medical record reviewer should decipher physicians’ and nurses’ notes and handwriting.  The reviewer must be familiar with common medical abbreviations.

Definition of medical terms can be included in a medical summary for quick reference.

Medical record review for litigation or insurance claims is a very important task.  The medical summary will help the attorney understand the various aspects of the case and find the information he/she is looking for quickly.  A good medical chronology or summary can be critical to the outcome of the case or claim for the injured.