Missing Medical Records – Piecing Together The Puzzle

Medical records are the key to providing legal proof of care. If they become the focus of a personal injury, malpractice or liability suit (toxic tort), without those records attorneys face an uphill battle that may prove difficult to win.

Health-care professionals have a legal obligation to maintain medical records, but sometimes that does not translate into orderly record keeping. In some cases once the medical record is obtained, it's mired in additional medical jargon and nearly impossible to decipher. A Certified Legal Nurse consultant (CLNC) can help decrypt complex medical terminology.

Documentation of care has become synonymous with care itself, and failure to document implies failure to provide care. Despite the introduction of charting by exception – a system that implies all standards have been met with a normal or expected response unless otherwise documented – the prevailing rule remains, "If it isn't documented, it hasn't been done." (Nurses Service Organization.)

Making sure documentation is available and accessible is not always an easy task. A medical record request is often made prior to the end of patient treatment, particularly if there is a pending trial or lawsuit. Therefore, in order to prepare a complete set of medical records, all subsequent records must be identified for acquisition as well.

So missing medical records for the case have been discovered, now what? The expertise of a CLNC is essential at this point because his or her specific training and skill is essential in assessing medical records and analyzing the case. CLNC's can:

• Identify, locate, review and interpret relevant medical records, hospital policies and procedures, other documents and tangible items.

• Organize, tab and paginate medical records for easy reference.

• Prepare chronologies of the medical events involved in a case.

• Summarize, translate and interpret medical records.

• Identify issues of tampering with the medical records.

• Screen medical malpractice cases for merit.

• Identify, locate, summarize and interpret applicable standards of care.

• Identify adherences to and deviations from these standards.

• Identify causation issues, assess damages/injuries and identify contributing factors.

• Identify and recommend potential defendants.

• Develop written reports for the attorney's use as study tools

In seeking fair and proper treatment where medical treatment or condition is at issue, it is only logical that everything possible be done to facilitate that goal. Locating, organizing and interpreting medical records is a big step in the right direction.