Avoid These 6 Costly Mistakes in Medical Narrative Summaries

Struggling with report rejections as an Independent Medical Examiner or Qualified Medical Evaluator? Thinking why your medical narrative summary is getting questioned or rejected? What you thought would save time is now costing more to fix? Don’t waste time searching for reasons. Instead, search for the right service provider.  

Want better results? Experience the difference by outsourcing medical narrative summaries to LezDo TechMed. We don’t just summarize, we bring clarity, structure, and purpose to your reports.  

But what’s really going wrong with your reports? In this blog, let’s break down the most frequent mistakes that make your narrative summaries weak, unreliable, or even inadmissible.

Common Mistakes in Medical Narrative Summaries You Make

1. Missing Key Medical Facts

Feeling like your report lacks key facts? It’s frustrating to spend valuable time reviewing records, only to be left with more questions than answers. So, why it happens? How can you avoid it next time?

Not going through all records

Focusing only on recent documents and ignoring old reports can miss key facts about how the injury started or what treatment was done earlier.  

Not reading records in the right order

When reports from different providers are not grouped properly, the dates often get mixed up. This breaks the timeline, and it becomes difficult to track how the condition changed.

Faster reviews

The chance of missing test results, symptom updates, treatment responses, and doctor observations can lead to incomplete conclusions.  

Not comparing information across reports

You don’t review whether symptoms, diagnoses, or treatment plans stay consistent over time, so you fail to identify contradictions or patterns in the case.  

Ignoring signs of prior injuries or conditions

Noticing the past issues in the medical records and assuming it as unimportant or irrelevant without proper review can lead to wrong conclusions.  

Forming an opinion too early

Making a judgment before going through all the records leads to focusing only on information that supports your opinion, which creates bias.  

Not checking if the records match the patient’s condition

Not comparing what the patient says during the medical examination with what’s written in the medical records. Sometimes, they may describe new symptoms and changes in their condition or describe the injury differently. If you miss this, you can’t write an accurate and balanced report.  

Not marking or noting key points while reading

You may not highlight or note down important information while reading the records. Later, you can’t remember where you saw certain details, so they end up missing in your report.

2. Copy-Paste Content

Relying on copy-paste content to save your time? Then what about the credibility of your reports?  

Copying medical jargon without simplifying

You may often tend to copy technical language directly from medical records without simplifying or explaining it, as you are familiar with the terms. For example, you may paste terms like L5-S1 posterior disc protrusion impinging the thecal sac exactly as it appears in the radiology report. This makes the report hard to understand for non-medical readers like attorneys, judges, or claim administrators.

Pasting diagnosis lists from different providers

You may include information from multiple providers, such as a primary care doctor, orthopedic surgeon, physical therapist, or chiropractor, all in one section of your report. This could include not only diagnoses but also exam findings, treatment notes, or other medical observations.  

If you don’t clearly explain who provided each piece of information and when it was recorded, it can lead to confusion and contradictions in your report.  

Copying without checking relevance

Sometimes you may copy the past symptoms and exam findings without checking whether they are still relevant to the patient’s current condition. The issue arises when outdated or resolved problems are written in the report as still ongoing. It gives a misleading impression of the patient’s current health.  

Leaving incomplete or unclear text

When you copy content quickly from scanned PDFs or digital medical records, you may not check whether the text is complete, clear, and fits well in your report. It leads to grammar mistakes and makes your report look rushed or unprofessional.  

Not summarizing or organizing content

Instead of highlighting what’s important, you may copy long sections from medical records, like full physical therapy notes or long doctor’s reports, without summarizing. This makes the report too long and filled with unnecessary details. Key findings may get lost, and the report may fail to clearly present your medical opinion.  

3. Incomplete Physical Examination

Thinking a quick physical exam is enough? If you don’t properly document your findings, it becomes hard to justify your conclusions and can make the entire report questionable.  

Inconsistent with reported symptoms
If the patient says they have pain or trouble moving, but your exam does not check or mention those areas, the report becomes inconsistent and unreliable.

Skipping specific tests
Failing to perform orthopedic or neurological tests that match the injury site shows that the exam wasn’t tailored to the case.  

4. Lack of Objective Measurements

If you simply write that range of motion is normal or muscle strength is adequate, it does not meet the standards required in a medical-legal report. You are expected to provide objective, measurable findings. Joint movement should be recorded in degrees, and muscle strength should be graded using a standard scale.  

For example, if a patient can only bend their knee to 60 degrees instead of the normal 135, it should be written in the report. These details are essential to determine how serious the limitation is.

5. Incomplete Documentation of Functional Limitations

Leaving out how the injury impacts basic tasks like lifting, bending, or standing reduces the value of your exam findings. If the patient has a shoulder injury, but you don’t perform tests related to shoulder movement or strength, it shows the exam wasn’t specific to their condition. This can make the report seem incomplete or careless.

6. Weak Causation Explanation

Not sure how to clearly explain what caused the condition? If your report doesn’t show how the condition developed or what factors contributed, your opinion may be challenged.

Giving just a one-line opinion

Giving a short, one-line statement about whether a condition is work-related or not work-related without explaining how you reached that opinion weakens your report.  

Not linking the diagnosis with the injury

If the report mentions the injury and the work activity but doesn’t explain how they are medically connected, it becomes incomplete. For example, a report might state that the worker lifted a heavy object and now has disc bulge. Without explaining how the lifting caused the disc problem, the report assumes a connection instead of proving it.  

Ignoring pre-existing or non-work-related causes

Medical records may show prior injuries, age-related changes, or natural degeneration. If these are not addressed, the opinion may appear focused only on the work event, ignoring other possible causes.  

In short,  

When your narrative summary misses key facts or reuses old templates, it can lead to rework, delays, and legal challenges, costing you both time and money. Partner with LezDo TechMed for accurate, case-specific narrative summaries that save you from costly corrections and get your summary right on the first try.