Common Pitfalls for Attorneys in Medical Record Review

When reviewing medical records for a case, attorneys must navigate a vast amount of complex information. Here are some of the top missed points, according to legal and medical articles, that can have a significant impact on a case:

• Inconsistencies and Contradictions: Attorneys often focus on the narrative but can miss minor contradictions that a medical professional would spot. This includes conflicting information within the same record, discrepancies between different providers, or statements that contradict the client's version of events.

• Gaps in Treatment: Missing records or unexplained gaps in a patient's care timeline can be a major red flag for the defense. 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), medication administration records, or billing records, all of which can contain crucial information. For example, a doctor's handwritten note or a medication not listed elsewhere could be a critical piece of evidence.

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

• Misinterpretation of Medical Terminology: A lawyer may misunderstand complex medical jargon, abbreviations, or shorthand, which can lead to a fundamental misinterpretation of the patient's condition or the care provided. This can cause an attorney to miss key details about a diagnosis, a doctor's rationale for a decision, or 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 thorough review requires showing a direct causal link between a specific action (or inaction) and the patient's harm.