Common Pitfalls for Attorneys in Medical Record Review

When reviewing medical records for a case, attorneys must work through a large volume of complex clinical information. These are some of the most commonly missed issues, and each one can significantly affect the outcome of a case:

• Inconsistencies and Contradictions: Attorneys often focus on the narrative but can miss minor imperfections and contradictions that an experienced medical professional would spot instantly. Most commonly, conflicting information within the same record and sometimes within the same note! Discrepancies between different providers' assessments, or statements that contradict the client's version of events (so common and damaging to cases).

• Gaps in Treatment: Missing records or unexplained gaps in a patient's care timeline can be a major red flag for the defense. An experienced medical professional reviewing your records can identify these gaps early. A delay in seeking treatment, a gap between appointments, or a missing specialist referral could be used to argue that the injury was not as severe as claimed or was caused by an intervening event.

• Failure to Obtain a Complete Record: It's a common error to assume a set of records is complete. Attorneys may not request specific records like diagnostic imaging (X-rays, MRIs). Often, imaging or labs are ordered in the provider's note but the results are missing from the record. Missing medication administration records or billing records can all contain crucial information needed to build a strong case.

• Overlooking Nuances in "Copy-Paste" Documentation: Electronic Health Records (EHRs) often contain "copy-paste" or templated notes, where previous entries can be duplicated. While this can seem like a shortcut to providers, it can hide a lack of updated assessments or a failure to document an evolving condition. An experienced medical professional's eye can spot these patterns and identify where a doctor's attention to the patient may have been lacking.

• Misinterpretation of Medical Terminology: A lawyer may misunderstand complex medical terminology, abbreviations (these can be the same abbreviations but when used in specific sentences they can have a whole new meaning), or shorthand, which can lead to a complete misinterpretation of the patient's condition or the care that was provided. This can cause you to miss key details about a diagnosis, a doctor's reasoning for a decision, or understanding the severity of a condition.

• Lack of Causal Link: While the records may document an injury, attorneys can sometimes fail to meticulously connect the injury to the alleged event. A complete review requires showing a direct causal link between a specific event and the patient's harm.

Before You Rely on a Record Set: A Quick Checklist

Before building strategy around a set of medical records, ask:

• Do the dates of service line up with the billing records?

• Does every ordered test, image and consult have a matching result in the file?

• Are medication administration records (MARs) included for any inpatient stay?

• Do nursing notes and provider notes describe the same condition at the same point in time?

• Is there a documented reason for every gap in care?

• If timing matters, has the EHR audit trail been requested?

If the answer to any of these is no, the record set may not tell the whole story.

If you and your team don't have time to dig into the charts at this level of detail, that's why I'm here. Email me at lindaackerfnp@clearadvantagelnc.com or learn more about my medical record review services, and let me do what I do best so you can do what you do best.

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