Organizing the Medical Record– Getting Ready for Expert Review

At the outset, it should be emphasized that counsel should make sure that ALL the relevant medical records have been obtained and are ready for submission to Medical Opinions Associates for review.  These include, but are not limited to, emergency room records or admission chart, operative reports, progress notes, nurses’ notes, physicians’ orders, lab reports, x-rays and other films, consultants’ reports, social worker notes, discharge summaries, autopsy reports, and death certificates.  The medical expert will base his/her judgment solely on the information submitted.

In readying the file for submission, counsel should determine why the care in question was desired, what care was actually rendered, the timeliness of that care, the appropriateness of that care (to the extent a lay review will permit), and the cause of the problematic result that brought the matter to question in the first place. Then, the information should be summarized by episode or provider for the reviewer.  This improves review efficiency and often obviates medical expert reviewer questions regarding timeframe/sequencing that would otherwise slow down the process.

Do not rely on the medical expert to ferret out the important medical-legal aspects of the case.  To do so will, at best, result in a less efficient review and, at worst, lead to errors and oversights that can impair the evaluation.  Record organization can contribute to a more efficient medical review.  Numbering pages, indexing sections, highlighting key facts and results sounds mundane, but can greatly help the reviewer make the best use of his/her time.  Once counsel reviews and carefully organizes the records, he/she is in a better position to approach Medical Opinions Associates for a full-scale evaluation, if the initial evaluation and economic and other factors warrant the investment.