Medical Records Summary: Its Role In Compensation Claims & Attorney Review

In the event of personal injury, medical malpractice, and even workers compensation claims, a medical summary may be required for use by the attorney in settling cases.


The medical record summary helps attorneys or other parties dealing with medical-legal cases or claims settlement cases understand a summary of the medical state of an individual, including any existing illness, injuries due to accidents at work, or all similar medical conditions for purposes of the law suit and compensation.

Medical record summaries are fact-based and are produced based on a systematic chart analysis, including details about the who, when, why, and where of a patient's various medical experiences.

Preparing a medical records review for an attorney takes dedicated practice. The clinical information is provided in a chronological or reverse chronological manner.

The most significant benefit of presenting such a report is that the lawyer does not need to return every medical record when preparing the lawsuit.

The critical thing is to be well-versed is the terminology of medical-legal science and the complexities of civil litigation.


Medical Record Review and Analysis Process


Medical record report and evaluation is nothing more than assessing the patient's healthcare data. An attorney does this by identifying, reviewing, interpreting, and analyzing the statistics and figures included in a medical report.

Medical report research and evaluation are beneficial not only to attorneys, but also to legal nursing consultants, medico-legal case review agencies, insurance workers, and claimants.

The following steps are used in the medical record review and analysis process:

  • Collecting and organizing patient reports
  • Consultation of healthcare services
  • Recognizing factors that contribute to alleged accidents or injuries
  • Making written reports that are summarized
  • Evaluating and comparing witness accounts
  • Making a chronology of events

In an insurance defence case, for example, the essential components of a medical records report are:

  • The date of injury, also known as the DOI, is an essential component of the description. The lawyer can only need details on one serious injury. However, the attorney must highlight any damages that are associated with the specific injury. The DOI aids in differentiating one injury from another in a plaintiff's medical table.
  • The patient's account of the cause of the accident or disability
  • Diagnosis
  • Treatment Centers and Dates of Treatment: In a personal injury situation, information about the different providers and the dates under which the services were provided is important.
  • This detail will be used throughout the hearings of court.
  • Diagnostic tests, medications, and recommendations are also part of the treatment plan (s).
  • Prognosis or chances of recovery
  • Persistent impairment, if any.
  • Future care needs, if any.
  • Details about previous as well as irrelevant medical treatment, if any.
  • The attorney must be well-versed in medical abbreviations. Whether anyone reading the medical report is familiar with the abbreviations, they should be included in the summary; since people confused with the abbreviations would be using the summary, the full form of the term or expression should be presented.
  • A medical description may provide definitions of medical terminology for easy reference.

Since they provide an outline of the medical/judicial problems, medical record summaries provided by legal nurse consultants appointed by lawyers are more authoritative and detailed.


Medical Records Summary Prepared by Legal Nurse Consultants


Legal nurse consultants (LNC) are specially trained to apply the nursing process to thoroughly evaluate relevant, complex cases in legal suits, as well as participate in client interviews and case strategy discussions where necessary. This helps lawyers better learn more about the nature and cause of injuries and how it impacts the legal issues in a case.

Some other important features of medical summaries provided by a legal consultant are:

  • An introduction is a critical component of the summary since it describes the case while emphasizing key details. Each series of medical records examined would be labelled.
  • They will use skilled formatting in the summaries, such as correct page numbers, headlines, footers, borders, ideally separated columns, sufficient spacing, and easy-to-read fonts, to easily understand the content.
  • They will restrict the use of abbreviations to avoid making the description sound like a medical chart and confusing the lawyer.
  • The explanation will be written in such a manner that even those with little understanding of medical language and symptoms will understand it. And if the solicitor is well-versed, they choose this style so the case can be moved from one attorney to another of less legal experience. This style is also useful for paralegals who are helping with the prosecution.
  • Medical evidence gathered from websites such as newspapers and internet research can be used to relate to the situation.
  • The medical review of an LNC would contain recommendations on the kinds of expert witnesses required, other witnesses to be questioned, and so on.

The medical review may be short or lengthy, depending on the needs of the lawyer. A short and quick review is usually a 1-2-page report highlighting the relevant activities and concerns while avoiding excessive detail. This type of summary is appropriate for an initial pre-litigation analysis or a guide for a case that the lawyer will reject.

A longer medical records summary/review for attorney may be and is usually a 2–10-page report that chronologically lists all relevant information. Important problems are explored in greater depth. Attorneys prefer this form of the summary for an initial assessment of a case prosecuted or one that the lawyer might consider.


Additional Help from Medical Billing Analysts for Fair Claim Resolution


Suppose you are a complainant or a claimant in a lawsuit. In that case, hospital costs are one of the most significant factors, say, in an automobile, personal injury, or medical malpractice litigation.

Calculating all treatment expenses can be difficult and specialist advice is sometimes necessary to ensure you have a good understanding of what is "fair and accurate" regarding the funds involved in your medical treatment.

In that case, hiring a medical billing and compensation specialist to assess and attest to the fair costs of medical services is useful and strongly advised. The position of the supplier will affect these expenses and reimbursements.

The Medical Billing Analysts team will analyze hospital, dental, and treatment bills to assess the worth of previous medical expenditures. They will also do a Risk Projection Analysis of possible costs based on local Current Procedural Terminology (CPT) codes.

Ultimately, through meticulous analysis of medical charges, they can explain and justify fair services costs, which aids in successful resolution of the case.

Joanna Hawkins is a content writer from the Medical Billing Analysts, Inc.