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The Medical Records Review

August 10, 2010

By Brook Hayes, UCLA - AATP - Owner of Discovery Is Continuing

You hear this creaking sound outside your office…it becomes louder and louder…the door to your office swings wide as a utility cart is pushed into your office, heavily laden with hundreds of pages of medical records. THE BOSS says “Great! Those records finally arrived…I am going to need a review and summary of those records ASAP!”

Whether you work for plaintiff counsel, defense counsel, medical provider, expert witness, consultant or other professional, there are a few things you can do to make the task more manageable and your Memorandum more coherent and beneficial to THE BOSS.

FIRST: You need to prepare a template or outline for your Memorandum to THE BOSS. I have found the following outline headings to be quite effective:

Summary Page (Patient name, DOB, date of incident, injuries, surgeries, potential problems);
Ambulance;
Hospital;
Medical;
Doctors;
Non-Medical Health Providers (i.e. chiropractors, acupuncturists, massage therapists);
Physical Therapy;
Radiology

It is also helpful to prepare your Memorandum with two sections utilizing the same headings…one for Treatment Related to the Subject Incident and one for Treatment Not Related to the Subject Incident.

SECOND: Grab a stack of stickie notes and go through the records, flagging all hospital history and physical summaries, hospital discharge summaries, surgery reports and radiology reports. This will give you a quick overview of the medical treatment tendered to the patient. Place numbers (1, 2, 3, etc.) on the flags for reference in your Memorandum (THE BOSS will appreciate being able to go straight to a numbered stickie as he/she reviews your Memorandum).

THIRD: Now is the time to look for those potential problems…the inaccuracies or discrepancies between what the patient has indicated and what the records reveal. We have all had the patient who denied any prior injuries only to see revealed in the medical records prior automobile accidents and/or worker's compensation claims.

Do a quick scan over all the treatment reports looking only for discrepancies and flag those reports which indicate potential problems. You will also want to pay particular attention to differences between the subjective complaints of the patient and the objective findings upon examination, as the treatment provider will oftentimes indicate in the treatment report if the patient is exaggerating symptoms or outright lying. Pay close attention to those handwritten notes as they are typically made as the treater is examining the patient (and may not make it into the final type-written report.)

I use a hard red tape flag (numbered as needed) for the problems or discrepancies and reference such in the Memorandum.

FOURTH: Next you need to look for discrepancies in how the subject incident occurred. I will go through the ambulance, emergency room reports, and hospital admission documents; in addition to, the initial treating reports from all medical and non-medical treatment providers. Pay particular attention to any statements or comments made by your patient to the treaters as some treaters will make hand written notations of such in the reports.

I will also use a hard red tape flag (numbered as needed) for any problems that I see in this part of the records.

FIFTH: Another thing to look for is notations indicating a subsequent injury, re-injury, or activity undertaken by the patient that has exacerbated the initial complaints of the patient. This occurs frequently. Again, I will make use of hard red tape flags (numbered as needed) for any of these occurrences.

FINALLY: Once you are finished with the cursory review and flagging of the records, then you will not only have a good working knowledge of the medical records, but will be able to easily prepare either a narrative summary or a detailed summary of the records for THE BOSS.

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