Dorothy Secol, CLA
  Home About Us Services News Resources  
Independent Paralegal Services for Attorneys
 

News

PERSONAL INJURY
SUMMARIZING MEDICAL RECORDS

In cases involving serious injuries, it is not unusual for a client to have multiple medical providers. You will have obtained medical records from each provider to get a full understanding of the extent of the client’s injuries and treatment plan. In the event there are pre-existing injuries, you may need to request those records, as well.

What do you do with these stacks of records? Before you scan and save these records on your computer, you need to organize and prepare medical summaries as each document is received.

  • Separate the records received from each provider. You may use index dividers especially if you are creating a medical records notebook.
     
  • For each medical provider you may break each tab of medical records into subsections:
  • Progress Notes
  • Nursing Notes
  • Xray, MRIs and other radiology reports
  • Referrals and prescriptions

This is a matter of preference; if you do not feel this is necessary you may skip this step.

  • Put the records in chronological order with the most recent on top.
     
  • Prepare a table of contents for the medical records index.
     
  • Scan and save a complete copy of the organized medical records on your computer.
     
  • Use software to Bates number the medical records. The Bates Stamp can be as simple as “Plaintiff-001” or however you wish to designate the description.

In medical malpractice cases, one of the most effective organizational tools you will find is in the creation of a timeline of the sequence of events in the hospital. The time line can be created in various ways, using charts, graphs, etc. The most important factor is charting the time from the patient’s chart, starting from the beginning, as to time when medicine was administered; time when procedures were done; time when x-rays, MRIs, scan, etc. were done; accounting for each and every second the client was in the hospital, receiving treatment. This way you will have a complete picture of everything that was done or was not done, in the hospital.

It is no longer sufficient to present information to the trier of fact without adding illustrations. Today, jurors, mediators and judges are so sophisticated that it is necessary to incorporate a combination of text and graphic depictions into settlement brochures, meetings and trials. Vivid demonstrative aids are useful for maintaining the interest of the trier of facts who have become accustomed to the graphics added to articles or television shows such as the news.

Medical summaries are enhanced with tables and charts, which re amount the most cost-effective exhibits. Selection of colors for exhibits can have a profound impact on readability and persuasiveness of an exhibit. Black letters on a yellow background are frequently used combinations for headings or for important information on a chart. Charts should also be prepared with adequate white space to avoid crowding of content.

Charts which are set up on columns can compare information such as the essential steps in the standard of care with the actions taken by the defendant. Software can be used to create graphs of medical visits, or to demonstrate a pattern of full time employment versus time spent out of work, etc.

Tables, prepared by an expert who has analyzed medical records, may present various aspects of pain and suffering. Pie charts, bar graphs and line charts are also visually appealing. Tables may point out inconsistencies in the plaintiff’s version of events, demonstrate that the patient withheld information from treating physicians or was noncompliant with medical treatment.

Whatever the nature of the litigation, your goal is to allow you to find a piece of information quickly and make sure it is viewed in the best light possible.

More News >>

 


Home  |  About Us  |  Services  |  News  | Resources

  Send mail to dorothy@dorothysecolcla.com with questions or comments about this web site.
  Copyright ©2009 by Dorothy Secol, CLA.