Medical records are the lifeblood of malpractice cases. Without the records, and a full understanding of what is contained in the records, the injured party may not be able to prove the negligence of the healthcare provider, establish causation, or prove damages. It is therefore imperative that all of the client’s medical records are reviewed closely. Overlooking any information contained in the records can result in losing a case.
A summary of the medical records should contain an overview of every encounter between the client and a healthcare provider, and include the diagnosis, treatment, test results, medications, and prescriptions. The review should also identify any errors in the records. An error in the records, in and of itself, can contribute to malpractice.
The summary can be used to identify any deviation from the standard of care. Additionally, it can isolate certain evidence supporting the claim.
A review and summary of the medical bills is also important because the CPT and ICD codes provide additional information about the treatment and diagnosis that may not be contained in the records. Also, the bills should be used as a resource to determine whether any medical records are missing. One missing medical record could be the key to winning a malpractice case.
Therefore, it is vital that a review and summary of a client’s medical records and bills are completed by individuals with experience in malpractice cases.