Medical Record Review for Attorneys: Best Practices

Medical records play several key roles in courts of law and litigation of all kinds. But, before they can appear in a case, they need to be found and reviewed by a legal team. A key part of that process is medical record review, to identify key information relevant to your case. 

Below, we’ll break down some of the key concepts in medical record review for attorneys.

We’ll provide a step-by-step guide to reviewing complex medical records documents, explain ways to use complex medical records once they’ve been reviewed, and preview tools that can facilitate everything about the medical records review process.

Essentials of Medical Record Review

Medical record review is the process of preparing patient and client documents for use in a legal case by collecting and carefully analyzing them. Legal teams that depend on treatment, billing, and related records as evidence need to ensure that they’re accurate and usable by confirming first that what is included in medical records is accurate and accessible. They’ll also need to ensure the information within them is consistent with what their clients say and the arguments they’re preparing to make or refute.

Another consideration is compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA governs data privacy in healthcare, controlling the flow of protected health information (PHI) such as patients’ treatment and payment records. Specifically, HIPAA most stringently protects identifiable PHI.¹ All documents with identifiers, which make them viable for most legal purposes, need to be protected to remain HIPAA compliant.

Relevance to Different Types of Cases

Medical records help legal teams define causality, and what specific trigger or catalyst caused an injury to happen, a condition to worsen, or another health outcome to occur. Similarly, they help experts determine who is liable for these occurrences, if anyone is, and to what extent.

Medical records also help determine appropriate compensation by triangulating timelines, outcomes, payments, and other phenomena with laws, actuarial calculations, and more.

The types of cases medical records are used in include personal injury, medical malpractice, such as misdiagnosis, failure to inform, and mistakes in applications or treatments. They’re also used in claims over worker compensation and wrongful death. Any case in which particulars of a person’s medical information or health condition matter may utilize medical records.

Step-by-Step Guide to Reviewing Medical Records

No two cases are identical, no matter how similar the underlying facts or assumptions might look. Every set of medical records is unique, and even two cases involving the same person’s records may necessitate looking at different documents or different parts of the same records.

All this is to say that the medical record review process needs to be tailored to the specifics of a given case. However, the bases you’ll need to cover are generally the same. They include:

• Identifying what specific records will be beneficial for the case and why
• Locating records and ensuring ease of access to them digitally or physically
• Requesting and/or using subpoenas to access records securely and legally
• Collecting documents and processing them to ensure seamless compliance
• Organizing and summarizing findings as addressable legal intelligence
• Preparing information for presentation across legislative contexts

Let’s take a closer look at two of the most important steps in the process.

Identifying Key Information

Before even looking for complex medical records, your team or law firm should identify the specific kinds of documents you’ll need and, further, what specific information on them you’ll want to focus on primarily for your medical records review.

Across regulatory contexts, one of the most important principles of data privacy is “minimum necessary.” That is, the amount of sensitive data collected, stored, and processed should be the minimum needed for its specific purposes. This is a core requirement within the HIPAA Privacy Rule, and it’s necessary to uphold even across otherwise permitted uses and disclosures.²

And, aside from compliance, optimizing record collection and processing to the least minimum principle is also a best practice for efficiency and focusing resources on the most critical tasks.

Organizing and Summarizing Findings

Effective record retrieval does not mean locating every single file and dumping them all into a shared location. Instead, you’ll want to comb through documents and ensure that the most important information is easy to find with organizational cues. Work with markup copies to visibly identify important information by highlighting it or redacting/removing irrelevant pages; use file and folder names strategically to ensure all parties can find what they need swiftly.

Another important element in the medical record retrieval process is creating summaries. Rather than expecting anyone who touches a case to read through the raw materials from start to finish at the onset, you should create summaries of the most important information that can be scanned quickly to bring legal professional teams, attorneys, and other concerned parties up to speed. This is a major benefit of automation—see below.

Leveraging Medical Records in Litigation

As noted above, medical records play myriad roles in courts of law. Some of the most pressing reasons you may call on accurate, compliant medical records in any given trial may include:

• Providing key context – Health conditions or medical treatment history can show that a client was or wasn’t present somewhere or is physically capable or incapable of something.

• Proving fault for injury – Detailed records of procedures and treatment may contain inculpatory or exculpatory evidence of (in)appropriate actions taken by a provider.

• Arguing for compensation – Histories of treatment can speak to improvements or degradations over time, which triangulate with other factors to inform payments.

• Debunking opposing arguments – Opponents’ claims may be refuted if you’re able to identify errors in their own medical record retrieval, analysis, or review processes.

What these use cases point to is the importance of accurate retrieval and review.

Common Medical Record Pitfalls to Avoid

The easiest mistakes to fall into with medical records stem from their volume and complexity, along with the possibility of errors, incompatibility, and inconsistencies across contexts. If one or more records contradict each other, in any way, it could spell trouble for even a rock-solid case.

Other major pitfalls relate to compliance. As noted above, HIPAA restricts the use and disclosure of identifiable PHI. Access to medical records might require a formal court order or subpoena to begin with. This requires both the requesting party and the HIPAA covered entity to take several precautions to notify any impacted parties and ensure PHI is safeguarded.³ These, in turn, can cause delays and other complications before and during a trial, compromising record access.

The best way to prevent and mitigate these and other issues is to implement a thorough and careful medical record review process in any case that will utilize medical documentation.

Tools and Software for Efficient Record Review

Medical record review is at its best when legal teams are deliberate and cautious. However, careful retrieval and review require dedicated resources that can hamper attorneys’ ability to give other strategic casework the time it deserves. That’s why legal teams are increasingly turning to outsourced medical record retrieval aided by cutting-edge third-party technology.

Some of the most useful software solutions to facilitate medical record review include:

• Intake surveys and review processes to determine import and potential issues
• Platforms and account management for efficient and secure file storage and access
• Query and analytical tools with reporting to a dashboard for at-a-glance insights
• Security and compliance assurance measures like risk monitoring and mitigation
• Artificial intelligence (AI) tools to automate document review and summarization

Third-party medical record review service providers often bundle some or all of these capacities to optimize the process.

U.S. Legal Support’s Medical Record Retrieval Services

U.S. Legal Support offers a suite of medical record retrieval and review services designed to help legal teams get the most out of relevant medical records. It all starts with an efficient collection led by an experienced team featuring relationships with over a million providers. We also have retrieval sites placed all across the country to optimize on-site collection.

Beyond retrieval, we also assist with analyzing, organizing, and preparing medical documents for maximum impact in trials and across legal proceedings. This includes customized summaries of records proper, trends and insights across them, and other key use cases, like depositions.

And, across all these processes, our HIPAA-compliant Client Portal keeps your team 100% compliant with HIPAA, SOC 2 TYPE 2,  and other key regulatory initiatives. Convenience shouldn’t compromise your compliance.

Streamlined Medical Record Review for Attorneys

Ultimately, medical record review for attorneys is an absolutely essential practice in any legal case that involves a client’s mental or physical health in any way. Being able to prove something happened to them, or that a doctor or medical expert did or didn’t perform a procedure correctly, can be the difference between a favorable or unfavorable outcome. And it all depends on retrieved medical records. 

U.S. Legal Support helps legal teams collect, analyze, summarize, and otherwise process records of all kinds and for all use cases. Our innovative technological solutions allow you to spend less time on rote or mechanical processes and more on critical strategic thinking.

To learn more about our record retrieval and review services, get in touch today!

Sources: 

1. The HIPAA Journal. What is Considered PHI Under HIPAA? https://www.hipaajournal.com/considered-phi-hipaa/
2. HHS. Summary of the HIPAA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
3. HHS. Court Orders and Subpoenas. https://www.hhs.gov/hipaa/for-individuals/court-orders-subpoenas/index.html

Julie Feller

Julie Feller is the Vice President of Marketing at U.S. Legal Support where she leads innovative marketing initiatives. With a proven track record in the legal industry, Juie previously served at Abacus Data Systems (now Caret Legal) where she played a pivotal role in providing cutting-edge technology platforms and services to legal professionals nationwide.