Overview

Medical record summaries are the summarized recording of the significant details from the medical record in chronological order to support the claim of the victim. It contains information on who, why, what, when, and where of the personal injury claim. These summaries are prepared especially for the personal injury lawyers who fall short in time to go through a medical record and are not well-versed with all the medical terminologies.

A medical record is the detailed documentation of a victim’s health issues throughout their lifetime with all the medications they have taken, and the diagnoses undertaken by them. It is usually scribed by healthcare providers. This is wholesome of data written down in hundreds of pages.

Any common man would find it boring and difficult to understand also I don’t have to mention the patience to read a booklet of thousand pages filled with medical terminologies. To read and understand a medical record requires a lot of experience and professionalism in the healthcare section whereas Lawyers are professionals expertized in the nuances of the law.

Although years of experience in personal injury claims can assist the Attorneys to gain some knowledge in the medical terminologies, the truth is it is impossible to have a thorough understanding unless you are a medical professional. This is when the need for a medical record summary arises and the medical record summary service providers.

Elements of a medical record summaries

  • Date of Injury
  • The cause for the injury as claimed by the victim
  • Diagnosis
  • The details of the treatment providers and the date of the treatments
  • The treatment plan includes reports of diagnoses, medications, and referrals
  • Prognosis
  • The details of Permanent disability, If any
  • The future medical needs of the patient
  • Information on prior medical treatments
  • Deciphering the medical terminologies, In medical record summaries the terminologies are written in full form at the first instance and the definition of medical terminologies is attached for reference.

The factors to consider before preparing a medical record summary

  • Chief complainant
  • Medical history, diagnoses, and treatment plan
  • Progress notes, nurses notes, consultations, and diagnoses study
  • Discharge summary
  • Prescribed medications
  • Healthcare providers recommendations on follow up

Types of medical record summaries

  • Comprehensive chronologies
  • Narrative summary
  • Chronological summary- Timelines and charts highlighting the treatments undergone from the relevant time period

The Process of Summarizing a Medical record

Summarizing a medical record is a process that involves a series of actions put together. Let’s have a look at them.

File Receipt

The original medical records are received from the healthcare providers. These records are transferred in a secure way making sure there is no loss of data.

Analysis and Categorization

Every piece of data in the medical record is analyzed thoroughly to take down points of the insights gathered. Also, the data in the medical records are categorized based on History, complaint, observations, diagnoses, treatment, and prescription, etc.

 Sorting and Organizing

The medical record is now sorted based on the time-frame of the incidents. This helps to organize the medical record by date.

Indexing

An index is created for the data in the medical record in chronological order by date in a forward or reverse manner.

Hyperlinking

Hyperlinks are attached in the summary so that on a click, it navigates to the respective page in the medical record.

Summarized records

The records are now summarized and generated in PDF or any other user-friendly format for easy understanding of the jury.

The uses of medical record summaries for an attorney

  • The medical record summary reports are considered to be the case overview. It has the complete medical history of the patient in chronological order. It helps the jury to understand the extent of the injury. It also allows the attorney to estimate a claim amount for the case. The Attorney negotiates with the at-fault person to settle the claim amount without getting to the jury by using this summary.
  • The medical record summary gives the attorney a lot of insights into the injury that occurred to the plaintiff. The attorney jot down points from the summary in order to negotiate with the at-fault party.
  • The attorney uses the medical record summary as his shield against any false claims accused by the at-fault party regarding any existing injuries. The medical record summaries will showcase every injury and treatment the claimant had. Therefore no false accuses can be made.
  • A tool to prepare the plaintiff to testify at the hearing. The plaintiff is given instructions about his injuries and what are the terms that will aid him to claim more money. This helps the plaintiff to act confident and explain all his problems, their severeness, and the future impact on them to the jury.
  • A healthcare provider cannot be handed over with the whole medical record and asked for an expert opinion. The medical record will sum up to thousand pages going through all the pages and giving an opinion is a tiring job anyone would refuse to do. Instead, if a healthcare provider is provided with a medical summary of just two to three pages, he/she can have a proper look at it and provide insights to the attorney on minute nuances an attorney would not consider significant.
  • A number of mitigation factors can be revealed on a closer study of the medical record summary.

Final Thoughts

In this blog, we had been discussing what a medical record is? How is it summarized? The factors considered to summarize a medical record. The types of medical record summaries; The process of summarizing a medical record, and the uses of a medical record. In all these topics we have focused on the information enlisted in a medical summary and how impactful those data are for a personal injury claim and how it supports the attorney to assist the plaintiff gets the deserved claim amount. So hope, now you have a clear understanding of why an attorney needs a medical record summary in a personal injury claim.