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A high-quality medical summary for a personal injury case is a concise, accurate chronology of the medical care provided to an injured plaintiff before and after an event. Its purpose is to give attorneys, consulting physicians, other consulting clinicians, vocational consultants, and life care planners the medical history they need as a basis for their opinions. RPC medical summaries are prepared by experienced legal nurse consultants and are an important component of our vocational assessments and life care plans. In this blog, you will learn how information is gathered for a medical summary and the components that make up a high-quality medical summary.
Given its wide audience, including attorneys, physicians, and consultants, a medical summary for a personal injury case should be written to be easily understood by any reader. It should cover all the pre-event and post-event medical records that can be obtained from the plaintiff’s past and current medical providers and from personnel files, workers’ compensation claim files, and disability benefit applications.
The summary writer begins by working with the responsible attorney and his/her staff to identify and gather all available documents. This includes not just medical records and billing records, but other documents that may lead the writer to identify additional medical records. For example:
- Records of first responders to the injury scene, whether police officers, fire fighters, or emergency medical services (EMS). In a motor vehicle accident, the police report details the vehicles involved, the direction of impact, and the relative position of the person(s) involved. It includes information on the use of safety devices (e.g., helmets, seat belts, or airbags), vehicle damage, demographic details, and often a brief narrative. Similarly, the first report of injury for a work-related incident may have the conditions of the area where the event occurred, what the injured person said about the event, bystanders’ witness statements, and pertinent details about the plaintiff’s condition when help arrived.
- Employment records, which may contain results of pre-employment physical examinations and details of workplace injuries and may lead the writer to identify workers’ compensation claim files. Employment records may also help the writer identify medical records through the plaintiff’s employer-sponsored health plan.
- Claims histories of health insurers, which allow the writer to identify what medical care the plaintiff received.
- Military records, which may contain results of medical examinations, service-related injuries, and disability ratings at discharge.
- Workers’ compensation files that may contain detailed information on past injuries, past medical care, activity restrictions, releases to return to work, and impairment ratings.
- Social Security Disability claim files, which may contain physician reports describing a person’s disabilities.
- Police reports and correctional records, which may indicate injuries noted at the time of arrest or which occurred while incarcerated.
Obtaining these records can take considerable time and effort. The summary writer should work with the responsible attorney and staff as early in the case as possible to request records voluntarily and to draft discovery requests.
A high-quality medical summary provides details of diagnoses, treatment, and prescriptions in chronological order. A high-quality medical summary is not a verbatim duplication of the records reviewed. It is an overall analysis of the medical information that gives the reader an accurate picture of pre-event medical conditions and treatment, the event that brought the litigation, the injuries incurred, the treatment provided, and the need for any future medical care related to the event. It also includes any opinions or recommendations of treating clinicians found in visit notes, independent medical examinations, work status reports, or other clinical reports. All medical records, whether related to the injury that is the subject of the litigation or not, should be included. For imaging studies and tests, the summary writer should obtain the actual images, not just the report by the physician or technician.
A medical summary need not have an entry for each medical record. For example, where a course of physical therapy generates notes for each visit, an entry for each visit is unnecessary. Instead, it may be more useful to note the plaintiff’s condition at the beginning of therapy, the therapy goals, the modalities used, the plaintiff’s condition at discharge, and the achievement of therapy goals.
In addition to summarizing the medical records received, the medical summary should identify missing medical records. The fact a medical record exists but has not been produced can be shown in several ways, for example:
- A medical bill with no accompanying medical record
- A CT, MRI or other image with no corresponding radiologist report or the reverse
- A reference to a provider whose records have not been produced in the medical records of another practitioner or facility
- Deposition testimony from the plaintiff discussing additional providers/facilities
- Providers listed on pharmacy records whose records have not been produced
- Medical records produced that are incomplete
- Plaintiff/Defense expert reports, any providers/records they have listed in their record review not currently in your current file
- Employment records
- VA records for those Plaintiffs who have served
- Attention to detail in the received records (on hand) for language involving previous encounters from the provider
RPC can provide samples of medical summaries properly redacted, upon request. For more information on RPC or to discuss a case, contact Theresa Comer, BSN, RN, LNCC, Certified Legal Nurse Consultant, at 512-371-8056 or tcomer@rpcconsulting.com