How to Review Medical Records: The Value of Legal Nurse Consultants
A thorough and thoughtful review of medical records is key to building a claim or defense in a legal proceeding. Yet, analyzing these records can prove to be challenging and sometimes overwhelming. Experience-based knowledge of patient care and medical record keeping is a strength of Legal Nurse Consultants. Specialized experience and knowledge allow them to more easily navigate this process. Nurses can perform a more detailed analysis than other members of the legal team. Their familiarity and expertise with the healthcare system allow them to identify irregularities or variants in the delivery of patient care.
Med Law Advisory Partners’ Legal Nurse Consultants have decades of experience reviewing records and determining the merits of a medical case, resulting in measurable, positive outcomes in legal cases. Learn more about how to review medical records and the value of Legal Nurse Consultants.
Request the Relevant Medical Records
When using medical records to build a claim or defense, legal teams must have documents requested through a specific process. Requesting medical records begins with identifying the relevant documents for each case. A Legal Nurse Consultant can easily recognize which records directly apply to the case and are critical for review. Then, additional providers may be identified during the review. Those records should be requested if they are pertinent to the case.
When the defense requests medical records, they may require a subpoena to receive the certified documents. Records such as fetal heart monitoring, HIV testing, and photographs or video may require a specific request. The Legal Nurse Consultant also ensures the request for medical records is HIPAA compliant. For more detailed information on how to request medical records, read our blog post on obtaining medical records.
Organize the Medical Records
Upon receiving medical records, a Legal Nurse Consultant organizes the documents. Then they perform a preliminary analysis of record completeness. Knowledge of the medical record’s typical contents based on facility type is key to determining what may be missing. From here, the record is bookmarked electronically by section and prepared for Bates stamping. Bates stamps, or Bates numbers, annotate the documents by page number and are usually preceded by letters that denote the provider or facility from which the records originated. Many programs will easily Bates stamp records electronically, including Adobe Acrobat.
Organizing the medical records allows for early identification of missing records and more efficient analysis by the nurse consultant. Consequently, records organization is a valuable benefit to the litigation team as a whole. Organizing records enables the team to identify litigation-critical data in the records more quickly.
Critically Analyze the Medical Records
After being organized, the medical records should be reviewed related to the particular case or filed complaint. A Legal Nurse Consultant’s involvement in this phase is crucial in determining what information, among the millions of data points in a medical record, is relevant to the case. This analysis should focus on any known case issues and other areas of concern appreciated by the nurse reviewer. Any required timelines or chronologies are completed concurrently with the records review. For further detailed information on specialty timelines, read Alicia Davis’ article in the American Association of Legal Nurse Consultants Journal of Legal Nurse Consulting.
Although the reports should be thorough, many aspects of the medical record are immaterial and therefore, may not be included. Upon finishing the review, the timeline should be further edited for relevancy. Only information pertinent to the claim should be noted in the reports.
Identify Medical Experts and Assist Legal Counsel in Retaining Qualified Experts
As a legal case proceeds, it may be necessary to identify what type of expert opinion will bolster the case. A Legal Nurse Consultant can help determine the specialty of expert needed and find the most qualified and experienced testifying expert to opine on the case.
Requirements for experts vary from state to state. Some states require an expert to be a licensed practitioner in that state, practicing in the area of opinion at the time of the alleged breach in the standard of care. The Legal Nurse Consultant must familiarize themselves with the requirements in each applicable state when searching for a qualified testifying expert. In some states, the Legal Nurse Consultant performing the initial records review can testify as a “fact witness” based on their knowledge of the records. Nurses may also testify regarding costs and billing. Additionally, Certified Life Care Planner nurses can develop life care plans and testify to damages. For more information, see the Med Law Advisory has blog article on Identifying Medical Malpractice Expert Witnesses.
Re-evaluate Medical Record Requests
Legal Nurse Consultants often receive partially fulfilled medical records requests. During the review process, the nurse consultant will note all missing records, illegible records, and records that are suspicious. The expertise of a nurse reviewer allows for quick identification of these issues. Full reviews may require secondary records requests.
How Med Law Advisory Partners Can Help
Obtaining and analyzing medical records for litigation purposes can be a complex process. Legal and risk management teams don’t always have the time, resources, and expertise to review clinical information and determine the merits of a medical case. With extensive knowledge of the health care industry and claims management expertise, Med Law Advisory Partners’ Legal Nurse Consultants help our clients review medical records to identify the issues that truly matter and guide strategy towards a favorable outcome.
Founded by Alicia Davis, RN, LNCC, Med Law Advisory Partners (and former ALN Consulting) provides resources and expertise in the areas of safe opioid prescribing, medical malpractice, and post-acute care litigation, including COVID-19 claims. Alicia and her team have worked with government entities, healthcare systems, insurers, and senior-living operators for nearly 20 years, helping mitigate risk and manage medical-legal and healthcare fraud claims.
Originally published July 6, 2017. Last reviewed Feb. 28, 2021.