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: Practical Paralegalism

Maximizing Medical Summaries: Simultaneously Build a Patient Dossier

By Lynne DeVenny

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In any kind of litigation involving injuries, you have to get to know the patient or injured party very well, regardless of what side of the fence you are working on. Reviewing medical records is an excellent way to do that.

Do more than merely summarize and review medical records for causation, treatment and prognosis issues related to the injured party's current case. Make the most of your valuable review time to simultaneously create a dossier with key background information to fully flesh out the injured party's history, and to assist in litigation-related activities, including answering discovery, preparing for depositions and trial, valuing the case and drafting settlement proposals.

Medical records usually provide a wealth of detailed personal information about the injured party, including:

Marital and family status
Vocational history
Pre-existing conditions, including substance abuse and mental health status
Current and prior medications
Prior surgeries, significant injuries and serious illnesses
Life expectancy factors, including smoking, alcohol intake, weight and congenital conditions

As you are reviewing records for medical issues directly related to the case you are working on, keep an eye out for important background information. Include any facts that you learn about the injured party's background at the beginning of your medical summary, where anyone working on the case in your office can easily review them.

For example, the beginning of a medical summary which includes background information obtained from medical records could look like this:

Not only will you get to know the injured party very well, but your supervising attorney will be impressed with both your attention to detail and creation of a highly informative dossier that can be useful throughout litigation.

___________________________

If you would like to read more about how I review and summarize medical records for civil litigation purposes, including workers' compensation cases, my supervising attorney, J. Griffin Morgan, and I wrote a book, Workers' Compensation Practice for Paralegals (Carolina Academic Press, 2008), which includes an entire chapter explaining how to summarize medical records. There is an extensive discussion of the relation of medical records to the key issues of causation, treatment, diagnosis, prognosis, permanent impairment, ability to work and future medical needs relevant to any kind of civil injury claim, including personal injury, wrongful death, medical malpractice and nursing home negligence.

Full post as published by Practical Paralegalism on March 16, 2010 (boomark / email).