Challenges in Medical Document Review for Malpractice Claims

Medical malpractice claims are often expensive and challenging to win due to their complexity. Proving a medical malpractice claim mainly revolves around the patient’s medical records. Traces of medical negligence or malpractice can be hidden among the multiple pages of medical documents.  

Even the chances of medical document tampering cannot be completely precluded, as legal outcomes of med-mal claims can significantly affect the reputations and careers of medical professionals and facilities. A precise medical document review can be of great help in establishing medical malpractice.

Identifying the hints of medical negligence or tampered records is not that easy. Without solving these kinds of puzzles, attorneys cannot move further in the legal proceedings. Let’s see the challenges attorneys face in medical document review while handling medical malpractice claims and how to rectify them.

Medical Document Review Challenges

Volume and complexity of documents

Medical documents in malpractice claims are usually voluminous and complex. They include A-Z documents on a patient’s detailed medical charts, lab results, radiology findings, recommendations for therapies or surgeries, physician notes, correspondence records, and discharge notes.  

The sheer volume of unorganized medical documents can be overwhelming, making it daunting for the attorneys to pinpoint crucial evidence to prove negligence.

Going through every document in search of traces of negligence can be time-consuming and requires due diligence. Making use of a structured document review process and advanced tools can help organize medical data efficiently.  

Experienced medical malpractice record reviewers will not leave any stone unturned until they locate proof of malpractice. Their medical negligence reviews will be accurate and precise with facts.

Unintelligible medical jargon

Legal professionals without any medical background may find it challenging as the documents contain complex abbreviations, medical terms, and procedure narratives. Misrepresentation of these medical terms can lead to misunderstanding and incorrect conclusions, affecting the case’s outcome.

Only expert medical document reviewers with vast experience in medical fields can interpret these complex terminologies and understand the complex procedures. Their medical legal case reviews simplify them without missing the essence and make medical procedures crystal clear for non-medical people.

Establishing the standard of care

Proving what the standard of care is in a particular specialty and how it was breached is vital in establishing the breach of the standard of care. Medical documents would show the types of care provided to the patient, but not what was not provided. A non-medical professional cannot find out the type of care that could have been provided under similar circumstances.

Medical professionals from the same specialty or field as the defendant can only understand the specific standard of care and what a breach of that care means. A document reviewer from the same field can assess the normal standard of care, whether it was met, and any deviations that occurred. They can clearly portray what should have been done instead of the care provided in their medical malpractice record review.

Poor medical documentation

Illegible and handwritten documents can make the medical malpractice review process hectic and impossible. There are chances for legal people to misinterpret health conditions or procedures. Missing records or incomplete records, too, make the patient’s medical history incomplete, preventing the attorneys from grasping out the strengths and weaknesses of the case.

Experienced document reviewers can locate the missing links and initiate the retrieval of the missing and incomplete records to make the document review complete. With their years of experience, they can comprehend illegible records or handwritten notes and provide coherent and valuable insights.

Discrepancies in treatment timelines

Establishing an accurate timeline of medical events is crucial in medical malpractice claims. Any discrepancies on dates and times noted in the documents can make matters worse. It will hinder comprehending the progression of the patient’s medical condition and the treatments provided.

Chart reviewers prepare a detailed chronology of all medical events that could align with witness statements and other vital evidence. This can prove the sequential order of medical events, progression or regression of pain levels, and inconsistencies of gaps in medical documents.

Identifying qualified expert witnesses

When the physicians who treated the patients turn out to be defendants and expert witnesses for the defense, there are chances for biased opinions. From prejudiced or partial medical opinions, lawyers cannot grasp the complete medical history of the patient. Many medical experts may not be ready to give expert testimony against the defendants.

Medical document review by experts can identify if the medical opinions of the expert witnesses or defense-favoring witnesses are biased or not by perusing the imaging and lab results. By conducting a thorough analysis, they can locate unbiased opinions and assist the attorneys in identifying potential medical experts to be included as expert witnesses.

Compliance with privacy laws

Patients’ medical documents are sensitive and need to abide by privacy laws such as HIPAA strictly while handling them. Data privacy and security play a vital role in managing these records. Unauthorized disclosure of patient information can lead to penalties and hinder the legal process.

People involved in medical malpractice case review should have proper training in HIPAA and other relevant privacy laws. Secure data handling is a must to prioritize protecting patient data confidentiality, which can be assured by trained med-mal reviewers.

To conclude,

Medical documentation review in medical malpractice cases is a detailed and demanding process that requires expertise, precision, and an understanding of both medical and legal principles. Overcoming these challenges can be highly overwhelming for legal people. Only experts in medical document review can handle these challenges efficiently, as they have experience in both medical and legal fields.