In medical litigation, there are some crucial areas to focus on when performing medical records review.

1. What Are the Core Medical Records to
Review in Medical Litigation?

2. In any personal injury case, the study of medical-legal issues involved can be challenging
and comprehensive, and would require detailed reading and skilful interpretation of the
various facts. The purpose of medical record review for attorneys is to provide the
attorney with a clear understanding of the facts specific to the case so that he/she can
analyze the case in tandem with the existing statutory and case law involving standard of
proof of medical causation, jurisdictional issues and compensability issues. Any medical
records review include the organization, summarization and analysis of medical records
by a medical review team comprising people with a sound knowledge of medicine and
experienced in interpreting the medical data. A good review team would include
physicians, registered nurses, legal nurse consultants, professionals from a medical
background and documentation specialists.
Medical Records Review -- Core Areas of the Medical Chart
Whatever the type of medical-related case or its circumstances, there are certain
important areas of the medical chart that must be surely reviewed. It is from these parts
of the record that the attorney can obtain important pieces of information about the care
provided to the patient and what did or did not occur during the treatment period. A
comprehensive review of medical records is to be done in any medical-legal case
whether for the plaintiff or defense.
The following are the crucial areas to review.
 Physicians’ orders: These are to be carefully reviewed to find out whether the
orders were carried out by the nurses and other clinical staff in a timely manner.
Their relevance to the patient’s diagnosis must also be considered.
 Lab reports: Lab results need to be reviewed and interpreted to learn about the
diagnosis of the patients. It is to be determined whether there are any abnormal
results that the physician may have overlooked and thereby left some health
condition undiagnosed.

3.  Progress notes: These records are important because they provide a timeline
regarding the patient’s condition from admission to discharge. They give a clear
perspective on the physicians’/nurses’ evaluation of the patient and contain
valuable information regarding the patient’s response to treatment and care.
 H&P report (History and Physical): This report is prepared after the first evaluation
of the patient. In this, the physician notes down details about the signs and
symptoms he/she observed, and the initial impression and diagnosis. H&P helps in
evaluating the physician’s services and determining whether the prescribed
treatment was appropriate. Prior medical history of the patient is a valuable tool
for alerting the physician about what must be done or avoided in the treatment
plan.
 Medication report: Medications are administered by the nurses in attendance and
are recorded in the medical record. This report provides information on the type of
medication given, the time and route of administration as well as the dosage. These
details will help identify any error or delay in treatment. The medication report
must be compared with the physicians’ orders.
Medical Review Solutions for a Clear Understanding of the Case
Let me conclude this article with a brief mention of what medical review solutions
generally comprise.

4.  Organize the medical records and other medically related litigation material
 Medical case chronology preparation (for medical events and timelines)
 Initial case screenings for merit and causation
 Analyze the records to identify standards of care, type and nature of injury and its
impact
 Identify and apply multidisciplinary standards of care and regulatory requirements
 Medical case summary preparation to help attorneys understand the various medical
facts and other issues relevant to the case.
1-800-670-2809 www.mosmedicalrecordreview.com