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Paralegal Practice Tip: Get the Story Right in Your Medical Summary

Paralegal Practice Tip: Get the Story Right in Your Medical Summary

When I’m summarizing medical records, I do more than only review the patient’s medical history. I try to get a sense of the patient’s personality, perspective, and life, using all of the documents available to me, not just the medical records.

I also include the dates and a brief description of key non-medical events in the timeline, so that my summary is not just a medical history, but is an accurate chronological narrative of important events, good, bad, or indifferent, that we need to consider during litigation, including (but not limited to, for you legal folk):

  1. Accidents/incidents/injuries (related and unrelated)
  2. Employment and termination dates, job changes, reviews
  3. Work status dates, including out of work (OOW), return to work (RTW), and/or physical restrictions
  4. Benefits award dates, including unemployment benefits, group disability benefits, or Social Security disability benefits
  5. Other key life events and/or stressors, such as marriages, divorces, childbirth, deaths in the family, and civil and criminal matters.

It’s funny how clear the big picture becomes when you carefully review and summarize all of the little snapshots of a real life that a set of medical records and other evidence can provide.

Got a tip for preparing medical summaries? Or for handling any aspect of your specialty area? I know each and every one of my legal professional readers is an expert in something 🙂

9 Responses to Paralegal Practice Tip: Get the Story Right in Your Medical Summary

  1. Great tip. I'll have to start doing this.

    Before I start a summary I go though the records with my highlighter and Post-It flags. Then when I'm ready to summarize, all the necessary and important info is already marked.

  2. Michelle, because we've been moving toward a paperless office for the last couple of years, I immediately scan medical records received "as is" and then use PDF software to do whatever I used to do with paper, including re-arrange, combine, markup and paginate.

    We got dual monitors at work about a year and a half ago, and I have the PDF medical records up on the portrait monitor and the medical summary with 7 categories: Date, Medical Provider, Doctor, S, O, A, P up on the landscape monitor, so I summarize as I read, which I usually do with any kind of paper evidence I'm reviewing.

    I could never have imagined such a paperless world 5 years ago! 🙂

  3. Thanks for the great tip! I have only been in the field for about 10 months and I am frequently asked to do summaries for workers' compensation hearings. When I have someone with mountains of issues (comp and non-comp) I find that I have trouble deciding what to include and what is superfluous. Thinking of it as a "story" rather than a summary may be what I needed to get more to the point and more efficient!

    Thanks, Lynne!

  4. Icchic, there's a whole chapter in the workers' compensation book my boss and I wrote about workers' compensation practice for paralegals about reviewing and summarizing medical records. A top notch summary helps in so many areas from case management to mediation and hearing preparation, that it's one of the most critical tasks I perform every day.

  5. I agree and I may have to pick up your book. I came to the legal profession after being in another career field for over 15 years and while my previous sales and customer service experience makes me comfortable with clients, I find that I have struggled with things like medical summaries and parsing out discovery documents.

    I have been reading so many blogs and have become involved in my local paralegal group and feel like I am learning every day.

    Your blog is such a wonderful addition to my extra curricular training!

    Thanks again, Lynne!

    Sharon

  6. Does anyone know of a software that helps summarize medical records? Maybe a macro that can be run on OCRed documents

Contact Info:

Lynne J. DeVenny, N.C. State Bar Certified Paralegal

Owner & Virtual Paralegal, DeVenny Paralegal Services

Email: lynne.devenny[at]gmail.com

Telephone: 336-582-0003

Inquiries are welcome, with free quotes available.

Meet Lynne:

Lynne DeVenny is a North Carolina State Bar Certified Paralegal with over 27 years of experience working on complex litigation cases, including medical malpractice, personal injury, workers’ compensation, and Social Security disability.

Disclosure: I am not a lawyer and cannot provide legal representation or legal advice.

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