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What is the Importance of Medical Record Review?

Medical malpractice cases turn on key facts, such as what treatment a doctor ordered and what information the doctor knew at the time of diagnosis or treatment. Often, it is difficult to piece together what happened after the fact, so medical records serve a vital purpose. By analyzing records, attorneys and others can reconstruct what happened in a way that makes a case come alive.

There is another reason why medical records need to be reviewed—determining the full extent of injuries caused by negligence requires the attorney know any pre-existing conditions that could impact a recovery. A full survey of a patient’s medical history is often necessary to determine what his or her condition was at the time of the treatment at issue.

What Records Are Reviewed?

There are many records that lawyers and their expert witnesses need to review. If a patient was admitted to the emergency room, for example, then we would review:

  • Admission demographic sheet
  • Consent for treatment forms
  • Nursing notes
  • Flow records
  • Physician assessments
  • Physician’s orders
  • Radiology reports
  • Lab reports
  • Discharge instructions
  • Discharge summary

Lawyers and their expert witnesses might also look at any medical record that has been created on a patient for the past several years, often with an eye to see if a condition is possibly pre-existing. For this reason, you should discuss your full medical history with your lawyer.

Some medical malpractice cases create voluminous medical records, all of which need to be reviewed with a careful eye. This can be a time-consuming process, but being thorough is key.

Why Are Records Reviewed?

To build a medical malpractice case, records are reviewed for several reasons. One of which is to create a timeline of events. A doctor’s treatment is only malpractice when it deviates from the accepted standard of care. However, what a doctor knows at any given moment about a patient’s condition is critical for determining whether care was adequate.

For example, a doctor who ignores obvious warning signs of internal bleeding could be negligent if she does not at least try to determine if the patient is bleeding internally. By contract, a doctor might not be negligent if a patient presents with no symptoms of internal bleeding.

In addition to failing to diagnose a condition, medical professionals can be negligent when they fail to provide a continuity of care. Often, this stems from a failure to communicate properly using medical records. If medical records are missing key pieces of information, or if key facts were not appropriately communicated, then this is some proof that malpractice has occurred.

In addition to creating a timeline, lawyers look to see what treatment was actually ordered. Many patients are unclear about what treatment they received, and medical review can clarify this.

Once lawyers have a strong grasp of the sequence of events, they are better prepared to conduct depositions in which they ask doctors and other defendants questions under oath. A deposition requires extensive preparation. Although it is common in a deposition to ask questions a lawyer does not know the answer to, our team needs some idea of what happened to make the deposition effective.

Who Reviews Medical Records?

Lawyers often will look at medical records. However, if they are too voluminous, then an attorney might hire additional staff to go through everything. This staff could be a qualified legal nurse consultant or paralegal who has the necessary training to understand the records and can put them in an order that makes them easy to understand.

Records are often assembled for review by an expert witness. New York law requires that lawyers file a Certificate of Merit when they file a medical malpractice case. This certificate states that the lawyer has consulted with at least one licensed physician who has reviewed the medical records and believes that the lawsuit has merit. Assembling medical records for review by a licensed physician is a necessary step in the evaluation of potential medical malpractice lawsuit before it is filed in New York.

Are Medical Records Used at Trial?

Yes. Medical records are often key pieces of evidence that are used to establish whether the defendant committed medical malpractice.  The medical expert witnesses at trial will rely upon the medical records to form the basis of their opinions.

For Help with a Medical Malpractice Case, Please Contact Us

Collecting medical records might seem like a wasteful task, but records are at the heart of medical malpractice cases.  At Powers & Santola, we are here to help collect the relevant medical records to review your case. If you believe you have received substandard care, then you should consult with an attorney at Powers & Santola, LLP today.

We are established attorneys who have helped injured patients hold doctors, hospitals, and other entities accountable when they provide negligent care. To speak with a lawyer, please schedule your free consultation today.

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