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):
- Accidents/incidents/injuries (related and unrelated)
- Employment and termination dates, job changes, reviews
- Work status dates, including out of work (OOW), return to work (RTW), and/or physical restrictions
- Benefits award dates, including unemployment benefits, group disability benefits, or Social Security disability benefits
- 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 🙂