Medical Documentation -- Getting Your Papers in Order

Proper documentation is essential for building a strong patient or client claim. To fully understand medical documentation and its technical terminology, you'll want the expertise of a legal nurse. Trained in medicine and knowledgeable regarding law, legal nurses can clarify important information to help you make a stronger case.

When considering medical documents and how they will best serve a case, you'll find the following procedures help keep things in order:

1. Review -- The main focus of a review of medical records should be on the treatment plan, how that plan was implemented and what the eventual outcomes were. A Certified Legal Nurse (CLN) can help deduce and define the key medical issues of the claim and help construct an effective case. Defining the issues can also lead to medical research and substantive background information, possibly with contributions from an expert witness.

2. From start to finish -- Once medical documentation has been reviewed and interpreted, a chronology can be created to show the course of events from the first diagnoses to the final results or most recent outcomes.

3. Sum it up -- Using the chronology, the events leading up to the case can be easily summarized. Once again, proper interpretation and attention to detail from an CLN will make this much easier and more accurate.

4. Compile information -- As mentioned before, medical documents can prompt further medical research, which will help in gathering new information, historical data and current information about the medical issues being addressed. Additionally, research sparked by medical documents can help determine not only the need for expert witnesses but also the type of experts needed.

In properly preparing a case, your documentation could be the key to how the case will be structured, where the focus of the case will be and what will be most needed to make your case stronger.