Medical record chronology, as the name implies, is the documentation of medical events in chronological order. However, it is challenging to produce a concise and unbiased medical chronology report for medico-legal businesses. One of the critical skills needed to extract relevant information is excellent communication, as the client is the primary source of the facts. It is paramount to determine the essential and non-essential facts for a potential future legal proceeding.
Compared to other medical record summaries, a medical chronology report is much easier to understand because the medical information is recorded per incident in a readable format. This helps the adjudicators—juries and other officers—in a legal proceeding or trial to understand the evidence presented clearly.
Usually the final product of a medical record will be delivered in a detailed summary which allows readers to better understand the sequence of medical events—and quickly.
Components of a standard medical record chronology report
Preparing a medical chronology requires a deep understanding of medical terminologies and procedures. This skill will ease the challenge of converting obscure entries from a treatment record into a readable format. The resulting report is significant in medical-legal cases as it plays a vital role in preparing for a deposition or trial.
A chronological medical report has the following kinds of information:
- Date of Injury (DOI)
- Cause of the injury or illness
- Medical history of the patient
- Diagnoses
- Handling physicians
- Dates of medical treatment
- Diagnostic reports, prescriptions, and referrals
- Recovery
- Permanent damage
- Future medical needs
- Unrelated medical treatment
- Summarizing handwritten notes of physicians and nurses
- Reference of medical terms
How can a medical chronology service help attorneys?
Attorneys often handle multiple cases at a time making it difficult for them to study and examine hundreds of medical records. It is time consuming to research, understand the medical jargon, and establish its relevance to their case. Fortunately, a medical chronology outsource service can help summarize a clear and accurate medical chronology report that details the extent of the injury.
A comprehensive medical chronology report assists attorneys to determine the validity of medical-legal cases and to identify the points for their arguments. Here is why a medical chronology report is essential for a case:
- Examining a plaintiff’s medical charts is a tedious and time-consuming process. Having a medical chronology report as a guide helps to understand the flow of events.
- A medical chronology report is a simplified version of complex medical terminologies that helps non-medical persons, juries, insurance carriers, attorneys, and people involved in a legal proceeding to better understand the circumstances.
Steps to prepare an accurate medical chronology report
Medical chronology reports are organized by a law firm’s in-house team or private service providers. The medical chronologists who prepare the reports implement specific steps to harness the value of the medical data in the medical charts.
Following are the steps you should follow when preparing a medical chronology report:
Start immediately: Facts of the medical events play a crucial role in the trial preparation. Start preparing the medical chronology promptly. Make sure to note down all the details given by the client; even the smallest detail provided could be the winning argument.
Acquiring the medical records: The best way to prepare medical chronology is by interviewing the clients. The next step is to identify and request medical records from healthcare providers.
Bates numbering: The medical chronologist numbers the records’ pages to identify data during the trial. Bates numbering is the legal term for numbering the pages and images in medical records.
Review the facts: Review the medical records and note the points in chronological order. Here the missing documents, errors, and medical record tampering are tagged.
Include all the facts: Never presume the importance of the facts in the medical records. Make sure to include all the facts even if the facts seem irrelevant, questionable, or disputed. The significance of the truth cannot be determined until the case is over.
Database software: Use database software to sort the data automatically. Additional features make chronological documentation easier, such as spellcheck, automatic day, and date.
Legitimate facts: The report preparation begins after the database software lists all the relevant facts. It is then followed by fact-checking and validating the relevance of the data.
Here are some tips to make your medical chronology report better:
Drafting chronological medical records is difficult yet necessary for the review process. Even a simple fact in the medical records could change the course of the case. However, a few steps could improve the quality of the medical chronology report.
- Sorting and indexing medical records is a complex process that could consume the attorney’s valuable time. Doing this will help avoid missing substantial evidence in personal injury and medical malpractice suits.
- Identify and uncover missing medical records – in a medico-legal case this can be the prima facie evidence that wins the case. It is necessary to document the dates, healthcare provider names, and record types to retrieve the missing records. This helps to search and collect the records quickly.
- Recognize and remove duplicate records to avoid confusion during medical litigation.
- In addition to text-based chronology reports, a pictorial representation of the timeline, including the date, physicians, and type of treatment, helps non-medical professionals involved in the case to understand the trial conveniently.
- Additional features such as bookmarking, hotlinks, or hyperlinks allow easy navigation to the original document for references in a click. A pop-up definition when hovering over a document can also save time when parsing through medical jargon or abbreviations.
- Preparing a medical trauma chart helps the plaintiff exhibit the extent of the trauma and the patient’s suffering.
- A separate record for prescriptions also makes it much easier for attorneys to refer rather than searching them through a pile of medical records.
- Maintaining a separate sheet for medical bills and jotting in chronological order helps highlight the bill incurred for the particular injury. Also, including a medical synopsis gives an overview of the treatment undergone or brief medical history.
Final Thoughts
A well-constructed medical chronology report can win or lose a case. A condensed medical record prepared with hyperlinks, synopsis, and other navigation techniques can speed up the retrieval and extraction process during a compressed legal time frame. A reliable service provider can be a great asset to obtain accurate and fact-focused medical record chronology reports.
PreludeSys is a leading medical records review service provider that offers customized, unbiased, and easy-to-read medical chronology reports for attorneys with a quick turnaround time. Our experienced team implements stringent security protocols to maintain data confidentiality.
Reach our experts to learn more about our medical records review services.
