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A medical chronology summary report, in simple terms, is a patient’s medical history listed in chronological order. It is a date-wise list of all the incidents concerning the medical history of the patient. It includes the date and time of visit, healthcare provider, patient’s injury, the treatment provided, the possible issues the patient would be facing in the future, a hyperlink to the referenced information, and the type of record.
It is also a crucial part of the medico-legal case. A good chronology provides facts and sources acceptable in a court aiding you win your case. A medical chronology report is different when compared to other legal and medical documents they are easily understandable for a wider audience who may not understand the legal and medical terms. It helps everyone in the trial understand the facts.
Need for a Medical Chronology Report
- Analyzing medical records for a personal injury claim is usually a long, complex, huge pile of data, tedious, and time consuming for a normal-lay person to find the essential data in the particular case. Through medical chronology summary services, you create a chronology report with all the pertinent data in brief.
- A medical record is a report incorporated of medical jargon that cannot be understood by the normal-lay people making the trial a complex one. But in a chronology report, only simple terms understandable by the attorney, jury, insurers, and all the people in the trial are used.
Elements of a Medical Record Chronology report
The medical record chronology report plays a significant role in the case, especially in a personal injury case. In preparing a medical chronology, deciphering the medical and legal jargon from the medical report and replacing them with easily understandable terms needs years of experience in the medical field. A company providing a medical chronology review service can help you create perfect medical chronology reports that assist your legal team to acquire your claim. The basic elements of a medical chronology report are listed below,
- Date of Injury or DOI
- Cause for the injury or illness
- Medical history of the patient
- Diagnosis or diagnoses
- Treatment Providers
- Dates of Treatment
- A treatment plan which would include diagnostic reports, prescriptions, and referrals
- Prognosis or the likelihood of recovery
- Permanent impairment, if any
- Future medical needs, if any
- Information about prior as well as unrelated medical treatment, if any
- Deciphering and summarizing notes and handwriting of physicians and nurses
- The definition of medical terms can be included in a medical summary for quick reference.
Medical Chronology Example
Steps to prepare a Medical Chronology Report
A medical chronology report is prepared by experts and companies that provide medical chronology summary services. These experts follow certain methods to draft a good chronology report that helps you win your claim. These steps are listed and explained below.
- Be prompt: The first and foremost step in preparing a chronology report is to begin straight away without any delay. Facts play a key role in the report. So, from the first moment you speak to the client, you start your preparation thereby you don’t miss any data given to you by the client also because every data given by the client is important. Some may seem unimportant at the beginning but will turn out to be the most pertinent information to win the case.
- Acquiring the Medical Records: The best way to start preparing a medical chronology report is by interviewing the client. Only by speaking to the client, you can extract pieces of information. We must determine the medical records that could be required for this case. To determine it, you identify the healthcare provider the client has visited. After identifying the provider they are requested for the medical records. In certain scenarios, if the client is a minor or mentally challenged the medical records cannot be lent without the consent certificate of the client. Now, if all the procedures are clear the medical records are released by the provider.
- Bates numbering: Now that all the medical records are obtained the companies that provide medical chronology summary services, or the firms start numbering the pages in the records. Each page in the medical record is numbered for identification of data in the future, for the trial. It also makes sure that no data is missed. This numbering system is called the Bates numbering system in the legal field.
- List down all the facts: The next step is reviewing all the records thoroughly. Each of the medical documents is assessed and the important facts are jotted down with the Bates number. By following this process, the data is documented in chronological order. In this process, a list of missing records, documentation errors, and medical record tampering will be highlighted because if any records are found missing later the case may not lead to the trial.
- Use of database software: In common, we use word processing software to prepare a chronology report whereas database software has numerous advantages over it. The most prominent advantage is, the database software sorts the data provided automatically and also adds the day for every date entered by the user. It saves a lot of time and also helps in spellcheck. By providing all these features it makes the process of documenting data in chronological order easy.
- Include all the facts: Entering every fact is a must while preparing a medical chronology report for litigations such as personal injury or workers’ compensation. Irrelevant to the importance of the fact, it is to be listed. Even facts that are questionable or disputed must be added. Some facts may seem to have no consequence in the case but still, they are to be added. As the value of a fact cannot be determined unless the case is over.
- Evaluate the Facts: Once all the facts are listed by using the database software the important part in the process of preparing a medical chronology report begins, evaluating the facts. Each fact listed in the report is evaluated for its relevance and validity. Now, the chronology report is a list of legitimate facts. Now, we have a medical chronology report consisting of the provider’s name, date, and time of treatment, facts related to the case, Bates number, and hyperlinks that navigate to the medical record from which the information was taken.
How to make your medical chronology report better:
Accurate and condensed medical chronology reports are prepared objectively and unbiased, providing all the necessary facts in an easily detectable format. However, while drafting the medical chronologies, if you include the following, it will abet you in winning your convoluted litigation, like a piece of cake.
- Medical record sorting/indexing:
Sorting out all the medical records pertaining to the case is hectic because some lawsuits will have huge piles of medical records. It will take many of your precious hours to search for your needed records. You should sort and index your records first. Properly arranged medical records will help discern the inevitable evidence crucial in personal injury, medical malpractice, or workers’ comp lawsuits.
- Missing record identification:
More than reviewing the medical records, identify the missing records, which are crucial to the cases. Missing medical records can tremendously impact even strong litigations, which can be won easily.
During your document evaluation, you should collect the provider’s name, the date of service, the next appointment, medical bills, and treatment gaps, which can then be compared to accessible data. Following that, a thorough list of missing records can be created, including dates, provider names, record types, and their significance to case analysis. Thus it will help you to retrieve the missing records easily.
- Duplicate records extraction:
When you gather the medical records, you may get different sets of records from various facilities. Sometimes, there are chances for many duplicate copies to be mixed with them. The presence of multiple duplicate records might create confusion during the litigation process. Recognizing and extracting the duplicates will reduce the size of the bulky documents and also avoid confusion.
- Treatment timeline:
After reviewing all the records, prepare a treatment timeline. A treatment timeline is a pictorial depiction of the significant events in the medical records in a chronological order. In a graphical representation of the chart, components such as the event name, the event date, and the facility/provider name are to be added. It’s like a synopsis of the entire treatment undergone by the patient.
Bookmarking means giving the gist of all your contents in the form of a table for easy navigation. You can bookmark your records in different methods. You can arrange them either chronologically or based on the list of providers the patient has visited or on the various medical record types.
Hyperlink the references in the medical chronology report to the medical records PDF. By clicking the hyperlinks in the linked document, you can easily navigate to the needed pages in the original documents. Instead of shuffling through the mammoth of records for specific points, you can access them with a click.
Med-a-Word enhances the comprehension of medical terms appearing in medical chronologies or narrative summary or deposition transcripts. Definitions will pop up once the reader hovers the mouse over the desired medical terminology. This is a boon to all in understanding the baffling medical terminologies.
- Medical bill analysis:
The medical bills incurred by the facilities or providers for the plaintiff’s treatment pertaining to the litigation are to be analyzed. Record them chronologically in separate sheets based on the providers’ names and types of the treatment availed. From the records, you can extract the treatment details and the amount spent. Note down the sum of the total cost of the treatment. If any amount is not related to the litigation, it also can be noted if required.
- Pain and suffering chart:
Like the special compensatory damages, non-economic damages like pain and suffering, emotional distress, anxiety, and discomfort, which stem from the injuries, also have significance. Therefore, prepare an interactive pain and suffering chart with information on the patient’s mental trauma and discomfort to convince the defendants or the insurance providers.
The pain and suffering chart records the date, provider’s name, and chief complaints, location of the pain, and pain scale. It also consists of the names of the pain medications taken and the dosages, prognosis, assessment, and treatment plan.
- Pain medication chart:
The pain medication chart captures the list of pain medications, the providers who prescribed them, and the dosage of each one. The chart highlights whether the particular medication is advocated to relieve inflammation, pain, or other injury conditions. It also records any allergy or after effect in the patient to the pain medication. Once you prepare that, you need not dive inside the ocean of records to check for the details whenever you need them.
- Medical synopsis:
Medical synopsis is specially formed to contain an overview of the precise medical history of the patient. It also points out the merits and demerits of the case to help in winning the litigation. Preparing a medical synopsis would give the reader an overall idea of the case, even without referring to the original records.
A good chronology report makes a great difference in your trial. It helps you acquire your claim in a short span of time and saving you from lengthy trials. These are some of the basic requirements to prepare a medical chronology report. Well-constructed medical chronologies with additional and special components like bookmarking, indexing, and hyperlinking would make your legal processes like a walk in the park. Good luck with you creating your chronological report.