How do you effectively review medical records?

Reviewing medical records requires persistence and significant attention to detail. Doing so can be cumbersome, especially if you are unfamiliar with the electronic medical record (EMR) system. Medical records usually hold the key details in medical malpractice cases for both the prosecution and defense.

What is the best way to organize medical records?

It is essential to organize your medical records chronologically and then catalog the sections. Next, you must make sure that the records are complete. Sometimes, physicians have incomplete records, which could make the job of the reviewer difficult. A patient’s visit to the hospital is a story and the medical records reveal the details. Reports should be separated into the various kinds of notes: nursing, hospitalist physician, specialist physician, other nonphysician specialists, radiology, and laboratory. Understanding the implications of these test results is imperative for the proper interpretation of the medical records.

Why is timing so important in medical records?

One of the most essential parts of the medical record is the timing of the event, test, or result. Timing is frequently essential in medicine. We say “time is brain”, or “time is heart” referring to the urgent need for intervention for stroke or heart attack patients.

For example, if a patient has the symptoms of a stroke and does not seek medical attention within 24 hours, it is likely too late to treat that stroke. Another example is if a patient walks into a busy ER waiting room, experiencing chest pain and having a heart attack, and isn’t seen for 30-45 minutes, his heart tissue is then being further compromised by the minute. Both these patients needed timely intervention. In the former case, the delay was due to the patient, and in the latter case, the delay may have been due to poor or overwhelmed systems. This too applies to sepsis, an infection that is systemic in the body. If sepsis is not dealt with in a timely manner, the infection can cause multi-organ damage.

Timely intervention is the standard of care.

Nurses’ notes often reveal very important information because they write details of each patient’s encounters as the events unfold. The physician notes are more intermittent but are typically routine to the time of the day patients are seen by the physician unless there is a new development in the case. In addition, physicians will often write their notes days after the event and their recall is unlikely to be as accurate as someone who writes the note at the time that they see the patients.

How do you determine if the care is a deviation from the standard of care?

There are plenty of events that can go wrong in the care of a patient. Not all of these events will have negative implications for the patient’s outcome. It takes medical knowledge and experience to determine what is significant to a case and more importantly if it deviates from the standard of care.

Standard of care in medicine refers to the care that a reasonable, similarly situated professional would have provided for that patient. For example, imagine a scenario where a patient who arrives at the ER in a rural hospital setting in the middle of the night and is having a heart attack. The ability to get a cardiologist and a cardiac catheterization team to expeditiously open up the closed blood vessel in the heart is much lower than in an urban setting, which is fully staffed 24/7.

Why does it make sense to have an experienced physician review medical records for an attorney?

While the task of reviewing medical records might seem straightforward for the purposes of a malpractice case and can be theoretically accomplished by a nurse, there are fundamental nuances that require the eye of an experienced physician to determine if there is a deviation from the standard of care. To win monetary compensation for an injury or loss related to medical negligence, the lawyer needs to prove causation, that there was substandard medical care and this resulted in the injury or loss in question. The most time-efficient and cost-efficient method for a lawyer to determine if a case is valid is to have a physician consultant evaluate the claim and review the medical record. Sometimes, the physician consultant can meet with the potential plaintiff to find out the details of their incident. It is also important to consider whether the potential plaintiff was a responsible participant in their own care. For example, a jury will not look favorably upon a plaintiff that is involved in the blame game but didn’t follow up with their doctor or take their prescribed medications.

A physician consultant can conduct deep dives into the patient’s medical records, capture vital information regarding their case and, if needed, perform literature research to bolster the patient’s case. In short, delegating the medical expertise to a physician consultant enables the lawyer to focus on the legal tasks and goals.

Paul Louis, M.D. is a full-time practicing Emergency Medicine Physician and part-time blogger.