The start of any case involving medical issues usually begins with gathering the relevant records. It’s always important to keep in mind there are pieces in the medical record that are not going to be turned over without separate requests. This particularly applies to films for x-ray and photographs. Many films are digital files now and are easier to share. 

PROTECTED RECORDS
You cannot typically obtain incident reports if you’re a plaintiff attorney until after the suit is filed. Even then, some states have rules that make it difficult to obtain incident reports.

OTHER RECORDS TO REQUEST
There are additional medical records or logs an attorney may need to request. For example, subsequent treating records are often useful to look at damages and also if you have questions about whether a portion of records was removed. You may find a critical piece of documentation in another provider’s records that has been removed from the treating physician’s records.

The providers the patient saw may have some bearing on the case. Health insurance records may provide a full listing of providers. Pharmacy dispensing records  are often useful to review regarding damages as well as to identify additional providers.

LOOK AT MEDICAL BILLING
Medical bills can verify if appointments took place. In one case, a young boy who had knee surgery developed a fat emboli in his leg. He went to his orthopedic surgeon’s office with complaints about his leg. The record of the visit disappeared from the office record, but there was a bill for the day which substantiated the family’s claim that he’d been in the doctor’s office.

AUTOPSY REPORTS
Autopsy findings reveal very surprising things. They uncover those secrets people literally wanted to get buried. Overall the rate of autopsies is dramatically declining in this country because of the medical legal climate and lack of insurance reimbursement. Give autopsy reports a careful review. 

GET THE BEST AND MOST COMPLETE RECORDS POSSIBLE
Make sure you exercise your right to get the best and most complete records possible. Analyzing medical records is challenging and complicated by an inability to read records or missing records. Don’t accept anything less than you need.

BE SKEPTICAL
Take into consideration that the record may not be accurate. Pieces may be missing. Be mindful of the fact that something could have been inadvertently written on the wrong chart or the information in the clinical piece doesn’t make sense, given the patient’s presentation.

DON'T GET SIDETRACKED
Another way you can get distracted is to look at the non-central issues, the things that are really not crucial for the analysis of a case. 

Getting caught up in looking at only one section of the chart and not looking at the whole chart can also result in overlooking relevant information. There might be important notations you’re overlooking if you don’t go through the entire record. That’s why attorneys often delegate this responsibility to legal nurse consultants. It is time-consuming to review a record; the attorney may miss information due an unfamiliarity with medical terms. 

DECIPHERING HANDWRITING
Although medical records are increasingly generated by computers, handwritten records still exist. It can be very challenging at times to try to interpret handwriting. Some states have a regulation that says the provider is required provide a transcription of the medical record. The plaintiff attorney may have to depose the doctor to obtain an understanding of the notes. The defendant is more likely to supply the defense attorney with a transcription.

BE SUSPICIOUS
Have a high index of suspicion when there are missing records or fraudulent records. By putting the pieces of the puzzle together, you can pick up on evidence of tampering and missing records. Watch for future blog posts for guidance on this point.

TAKE YOUR TIME
You can review a record too hastily. Suppose you are a plaintiff attorney and a client comes to you near the end of the statute of limitations. Some attorneys won’t even take those cases because they’re fearful of not having enough time to investigate. If you’ve got to do something at the last minute, you’re at risk for overlooking things. It’s a problem we run into when rushing and feel the pressure to get a conclusion together. 


 

THE VALUE OF A LEGAL NURSE CONSULTANT
As a Legal Nurse Consultant, I have the knowledge and experience to gather the relevant records, analyze the information, and determine what is missing. I handle the research so you can focus on the client and other matters related to the case.