From a Legal Perspective:
Preparing a flawless medical summary report, especially in those instances when the same is being prepared for an attorney’s review requires years of experience.
The most important thing in this instance for the summarizer is to be well versed in medical as well as legal terminologies and also understand the nuances of civil litigation.
Although a medical summary report is prepared for a specific reason, the report may become a public document and be used by diverse non-medical background professionals.
Therefore clarity of communication and economy of scale is really important for maximizing its effectiveness.
Any injury claim requires the preparation of a chronological medical summary report that will help in understanding the nature of the injury, the patients past medical history and its impact on the injury and any other vital information.
For an attorney, this can help him in evaluating a claim by understanding the injury and its relationship to the incident in question.
Therefore medical summary report is significant in that it will be used for discovery and investigation, for preparing for trial, for reporting to the claims adjuster and for preparation of exhibits and witnesses list too.
Therefore, these are the most important elements that need to be kept in mind while summarising a medical record:
1. Date and background of Injury:
This is a critical element in a summary. The attorney may need information regarding one injury or a specific injury only. But the summarizer must highlight all injuries related to that particular injury. The date of the incident thus helps distinguish one injury from the another in a plaintiff’s medical chart. It would also be best if there is a verbatim recount of the patient’s critical issues. Also, a brief mention of any relevant medical conditions would be considered appropriate.
2. Causation of the injury or illness as reported by the patient
3. Diagnosis or diagnoses – Comments on the general presentation of the patient should be included. Emotional, psychiatric and intellectual state of the patient along with the effects of alcohol or other drugs should be described in detail. Relevant negative findings should also be recorded. If there was any difficulty or limitation that was encountered during the examination as specified in the record, the same should also be included in the summary.
4. Names of the Treatment Providers and the date of treatment: Information regarding the name of the providers and the date on which services were provided by those providers is crucial in an injury case. This information will be used throughout the case proceeding.
5. The treatment plan which would include diagnostic reports, prescriptions and referrals made, if any.
6. Prognosis or the likelihood of recovery
7. Permanent impairment, if any
8. Future medical needs, if any
9. Information regarding prior or unrelated treatment, if any
10. Deciphering and summarizing physicians’ and nurses notes and handwriting. The summarizer, when including any abbreviations in the summary, must keep in mind that the abbreviations are such which are easily understandable to a person reading through the summary.
11. Definition of medical terms can be included in the medical summary for quick reference
A medical record summary is, therefore, a very important task that a summarizer is entrusted with.
A good medical summary may be critical to the outcome of a case.