Medical Record Review
As an orthopedic expert witness the basis for evaluation of any claim is a thorough and complete review of the medical records. An accurate chronology of events as well as correlation of the multiple disciplines involved in the administration of medical services must be assembled to establish a credible foundation for any claim. This includes laboratory, imaging, rehabilitation, and nursing observations as well as the physicians’ documentation in progress notes or hospital records. The more organized and concise form in which the material is presented the more expeditious and accurate the conclusions of that review can be rendered.
Significant cost savings can be achieved if the original format conforms to these specifications. I am experienced in reviewing the court documents and inclusion of disclosure statements greatly aid in evaluation of the salient points of the clinical record. A nurse paralegal summary is encouraged so the reviewer’s time is spent on the most salient portions of the record as they directly relate to the merits of the case.
All imaging data should be correlated not only with a radiologist’s interpretation but also the orthopedic surgeon/reviewer evaluation of the imaging study. Radiologists are trained to read the X-ray for content of the study and to offer a differential diagnosis. The radiologist is limited however, by a lack of specific knowledge of orthopedic diagnosis, surgical technique, proper nomenclature for injury patterns or deformities, and in particular failure to recognize or classify orthopedic implants or fixation devices.
Laboratory, pharmacy, and nursing observations are often overlooked in reviewing records for litigation or insurance claims. The nuances that are gleaned from correlation of this important data often will lead to additional avenues of investigation and are valuable additions to establishing a sound basis for a reviewer’s conclusion. This information is often of great value as an exhibit at time of trial and can give a jury the true flavor of a clinical picture through appreciation of pain medication use, changes in vital signs, or difficulties encountered with performance of nursing care or patients’ activities at home, hospital, or long term care facility.
Do you need a medical record review? Call Marc J. Rosen, MD at 602-298-8888 for more information!
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