Medical Case History and Summary - an Important Process in Medical Record Review

There was this young lawyer with a rather tough trial coming up, tussling with the many medical records of a patient. The erratic order of the records, difficult medical jargon and terminology, missing details, missing records – all these issues were taking a toll on him. It is only natural that in such trying circumstances you lose the capacity of clear thinking, a capability you just cannot afford to lose during trial preparation. Busy lawyers themselves and their office staff can prepare well for an upcoming trial if they choose to outsource the medical record review tasks to external providers that are trustworthy. Medical case history and summary is one of the most useful services you can avail of from the service provider.

Medical case history and medical case summary highlight important healthcare information that lies deep down in the patient’s medical records. Preparing concise histories and summaries calls for considerable expertise in reviewing the medical records, identifying the really important facts, and in making sense of medical terminology and various abbreviations physicians normally use. A lawyer may lack this expertise, while experienced medical review professionals can be of great assistance in preparing the crucial medical case history and summary.

The medical records relevant to a case are reviewed in detail and a summary is prepared with details such as the patient’s personal data, particulars of the injury/illness, medications administered and other facts arranged systematically. The crucial medical facts are thus available at your fingertips; additional advantages include valuable time and cost savings.

Like any other job, preparation of medical case history and summary calls for professionalism if it is to be carried out flawlessly. What can be more frustrating than irrelevant and confusing medical details finding their way into medical case summaries? This is what may happen if the record review is done by untrained staff. The professional medical reviewer will never let this happen. Trained in the job, experienced medical record review staff has the knowledge, exposure, expertise and an eye for detail that help them identify and abstract only the relevant data. They are well-versed in medical procedures and terms as well as the common abbreviations physicians use. Moreover, they can easily find out if vital records or details are missing.

Why Medical Case History and Summary Is Important

• It brings to light all information about the medical condition of the patient and the services rendered.
• Even the smallest relevant details of a case can be easily understood, and this facilitates speedy decision making.
• Accurate summaries help evaluate whether there has been medical negligence or deviation from the required standards of care.
• All areas of concern and dubious events can be identified.
• Pre-existing medical conditions that may have an impact on the case can be identified.

Medical and legal entities primarily benefit from getting to do what they love to do – practicing medicine and law. The right medical review company can bring the enthusiasm back into your life, allowing you to spend time on activities that demand more personal attention. Apart from sharing the responsibility of preparing medical case history and summary, your service provider will also ensure benefits such as:

• Prompt, cost-effective services
• Competitive pricing with cost savings in the range of 40%
• Customized turnaround time
• 24/7 service