How to Prepare Medical Records for Litigation

Preparing medical records for litigation requires review and organization.

Preparing medical records for litigation is first an exercise in organization. A "Table of Contents" is helpful to establish in establishing records you have and those that you still might need to seek. It also allows you to refer to the source of the information you obtain by citing an alphanumeric code as opposed to a longer description. A "Chronology" will help in comparing the medical care provided against established standards of medical care or in underscoring inconsistencies in injury presentations.

Things You'll Need

• Large 3-ring binders
• Clip binders
• Dividing tabs
• Highlighters

Instructions

1. 

   A table of contents and chronology can answer many questions first obscured by sheer volume.

   Determine and label the information you have. For instance, one group of papers may be clinic notes from the patient's outpatient doctor while another might be copies of hospital chart from an inpatient stay. Some records may be from an outpatient therapy clinic. Many of these records may be from during the same time period. Collate these records according to their source. Label the records from each source with a unique alphanumeric code. Begin a working Table of Contents from these records.

2. Establish a complete timeline - a Chronology - of the time frame represented by all the medical records. Use three columns: the first for the date, the largest for your summary and the last for indicating the source of the information. Inpatient records will require an hour-by-hour or sooner chronology. Outpatient records can be listed by the calendar date. Beside the time or date, write a brief summary of the event.

3. Make a page-sized chart to compare the accepted standards of medical or nursing care against the care documented in the medical records you have reviewed for litigation involving allegations of malpractice. For other cases, the case attorneys may find summaries with important findings or inconsistencies highlighted helpful. If depositions have not been completed, a list of questions can be prepared for healthcare providers based upon omissions in the record.

Tips & Warnings

• Whatever the nature of the litigation, your goal is to allow any member of the trial team to be able to find a piece of information quickly. Modify the organization and summaries of the medical records to meet the needs of the team.

• Any comparison of a published standard of medical or nursing care against the care documented in the medical record must be reviewed by a medical expert before discrepancies between the two can be alleged.

References

• "Medical Malpractice Claims Investigation: A Step-by-Step Approach"; Nancy Acervo-Abalone, et al.; 1997
• United States Department of Labor; Bureau of Labor Statistics; Occupational Outlook Handbook, 2010-11 Edition; Paralegals and Legal Assistants
• U.S. Department of Health & Human Services; Agency for Healthcare Research & Quality; Medical Liability Reform & Patient Safety Initiative
• "Electronic Discovery and Electronic Medical Records: Does the Threat of Litigation a?ect Firm Decisions to Adopt Technology?"; Amalia R. Miller, et al.; April 27, 2009
• LSU Law Center.edu; Medical and Public Health Law Site; Medical Records in Litigation