Common Pitfalls for Attorneys in Medical Record Review

When reviewing medical records for a case, attorneys must navigate an endless amount of complex information. Here are some of the top missed points, I found across the internet that can have a significant impact on 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 provider's 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, having an experienced medical professional reviewing your records helps to capture these gaps seamlessly. 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), many times imaging or labs are ordered within the provider's note but the record itself is missing. 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.

I hope this helps you look at your medical records with a fine tooth comb and if you find you don't have time to dig through the details, don't worry, I'm here to help!