A patient’s medical record serves as the evidence in litigious matters as it provides insight into the applicable standard of care received by the patient. Medical chart review is carried out to evaluate the patient’s health history, injuries, medications received, clinical inferences, care plans and much more. Accurate and comprehensive details of patient data are used by attorneys to prepare for the trial. Medical litigations are built around medical records as they are the only authentic source to obtain an objective analysis of the patient’s conditions and care.
A medical chart comprises the following data:
• Demographics
• Vital signs
• Medications
• Treatment strategies
• Surgical history
• Radiology images
• Progress notes made by the physicians
• Medical history of patient’s family
• Social history
• Habits (If the patient has substance abuse, it will be recorded)
• Medical encounters
• Progress notes
Medical chart review is the evaluation of previously recorded patient data like identity, treatments undergone, diagnostic test resultsand other details to answer specific clinical queries in a less resource intensive manner. Accurate documentation of patient data is vital for physicians to prove that they have provided standard care to their patients. It defends doctors and medical organizations when wrongful insurance claims or medical lawsuits are alleged. Lack of important details or inaccuracy can lead to legal and financial implications.
Why do attorneys and paralegals need medical records?
Attorneys rely on medical records for legal proceedings including personal injury cases, workers’ compensation cases, product liability cases, medical malpractice and medical negligence cases to name a few. Medical records document the patient encounters, clinical findings, pre-operative care, post-operative care, diagnostic test results and patient’s progress after receiving medications. Therefore, it is the important evidence that can be kept as court exhibits.
Importance of medical chart review in medical litigation
In medical malpractice claims, the plaintiff has to prove that there was negligence from physicians in rendering the necessary care. Clinical errors, prescription errors, and delay in diagnosis results are aspects of medical malpractice. Medical malpractice claims come under “tort law” which implies that the negligent individual is legally responsible to pay compensation to the injured patient.
Personal injury law is a branch of tort law and in such incidents medical chart is the substantiating evidence to strengthen the arguments put forth by the attorneys for the plaintiff. The patients who are injured physically, psychologically and emotionally are legally entitled for compensation from the negligent individuals.
Medical records are collected for this purpose and reviewed closely to compute the monetary compensation that can meet the medical expenses. But medical records can be accessed only by the patient and the healthcare provider treating the patient for a specific condition as they contain highly confidential patientdata. However, attorneys can access the records by obtaining authorization from their clients.
After collecting all the medical records, they are thoroughly reviewed to study subtle nuances of the case. Medical record review for attorneys is a hectic and time-consuming process. It is a multi-stage process beginning from the collection of relevant records.
Medical records are reviewed to analyze:
• Nature of injury
• Severity of the injury
• Location of the injury
• Date of the incident
• Diagnose results
• Clinical observations
• Degree of disability, if any
• Expenses incurred for the treatment
So, the onus of maintaining medical records properly is on healthcare organizations. It is beneficial for both physicians and patients to avoid the risk of legal liability.