MEDICAL RECORD REVIEW
Medical record review is the ready reference to entire medical history of a patient, and a precisely written documentation considering relevant and important incidences with regard to the patient. They are easy to read, comprehensive and cross referenced. By creating condensed version of the medical records according to client specifics, the medical records are accessed and efficiently up-dated.
The summary helps its user determine the key points in a document. Medical summaries indicate and highlight medical information for a given case. It helps the physician or the legal expert identify strength and weaknesses of the case. It helps easy visualization of treatment timeframe and decreases the review time. Medical Summaries correlate record review of the case with the preexisting medical condition or past medical condition which pertain to the current medical condition of a patient.
Types of Summaries
- Comprehensive Summary : It includes in detail almost every aspect of the medical records. This is an extensive summary mentioning each and every occurrence in the case. These summaries provide in-depth review of the medical records. The details especially are useful in toxic tort, personal injuries, medical negligence and cases where detailed analysis of records is required
- Narrative Summary : This pertains to connected events or the sequence which is described in a case. This only deals with specifics or a requirement from the client. It provides a concise description of information contained in the records. This is the brief synopsis of the most pertinent information.
- Annotative Medical Chronology : Only critical or explanatory notes pertaining to a particular case. It provides an overview of the medical records with a few words describing what they pertain to, including the dates of service. It is a perfect option for those who are short on time or merely want their records sorted and indexed for easy reference and accessibility.
- Indexing : This involves marking the records provided and indexing them with the page numbers. It is useful as a ready reference to trace the records when they are numerous.
The timelines are identified according to the type of cases. Sorting and indexing of the records is the first step in identifying timelines. The medical history relevant to the claimant’s injury is indicated in the timelines. There is overview of the past medical records and the current medical status. A glossary is done with case specific medical terminology and the acronyms.
They are useful in cases involving:
- Motor vehicle accidents
- Slip and fall injuries
- Workers' compensation cases
- Medical negligence of Medical malpractice
- Social Security Disability/liabilities
- Veterans Affair related cases
Summaries are needed by
- Attorneys and Law-firms handling medicolegal cases.
- Workman Compensation Doctors
- Insurance Claim Adjusters
- Agreed Medical Examiners/Qualified Medical Examiners/Independent Medical Examiners
- Medico-Legal Experts
- Forensic Experts
Process of Summarization:
- First the records are sorted and indexed.
- Relevant symptoms and treatment history is flagged.
- Timelines are created and charts are made highlighting treatment and relevant procedures.
- Missing records and bills are identified.
- The records are then organized, chronologies are built, and after this the records are reviewed and interpreted.
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