Critical Steps to Organizing a Medical Record

An organized medical record is the cornerstone of any negligence case.  Since the record is the most important material upon which your expert will rely, proper data preparation is instrumental to your success.  Adhering to these rules will reduce your cost and improve your success by allowing your expert to readily access key information in the most time-effective manner:

1. Collect all medical records and maintain them in their original order.  Perform Bates numbering if possible. Do not place any other notes or marks on the records.
2. Print all records and place them in a 3-ring binder.  Label the spine of the binder with your firm’s name and the name of the case.
3. If PDF is available, it may be included as a supplement to the printed volume.  PDF is never a preferred format since it precludes the expert’s ability to quickly identify pertinent pages and sections.  Remember:  When reviewing records, time is money.
4. Index the printed records by placing a tabbed divider between major sections.  Major sections are defined as medical records unique to a specific provider or institution.  If pleadings or other documents are included, include them under their own tab at the back of the binder.
5. Sub-indexing is not necessary, though it may be performed within major sections.  For example, tabbed dividers within major sections may identify dictated reports, laboratory data, imaging studies, orders, nursing records, etc.
6. Once the records are bound and indexed, prepare a Table of Contents identifying major sections and subsections.  Print the TOC on office stationery and insert it as the first page so that the expert has all of your contact information at the front of the binder.
7. The final step is to prepare a cover letter to provide a road map for record review.  The cover letter should summarize general facts and outline key names, dates, and places.  Within the cover letter, you may include additional information such as event timelines, tabular data (e.g. laboratory results), case theories, and specific questions.  Any discoverable information may be included, though a standard disclaimer is warranted: The case summary and timeline is furnished as a courtesy and is not intended to substitute for your full and impartial case review. In the rare event that an unforeseen conflict of interest is identified, ask the expert to close the file and contact you.
8. Provide a specific deadline by which the records must be reviewed, and give a direct phone number at which the expert may reach you.

Your time and your expert’s time are both important. A properly prepared medical record is the key to maximizing your case potential. When you work with Elite you not only get leading medical experts, you receive strategic consulting from our in-house team of physicians or nurses throughout the entire case. Contact us today to find the right medical expert for your case.