Our Services: Medical records
Are you tired of continually trying to find information
in a medical record?
 We
see all kinds of medical records come into our office, from
the meticulously organized to the totally unorganized. We
recommend that you consider using this system for handling
your medical records.
1. Obtain
hospital chart dividers from a hospital supplier or a legal
supplier. The most economical dividers are made of heavy
paper with plastic coated tabs that mark the various sections
of the chart. There are dividers for hospital charts as
well as for nursing home charts.
2. Have your consultant start
at the top of the stack and place the pages into piles that
correspond with each divider. Once each paper is sorted
into the right category, have each section organized in
chronological order, starting with the first day of the
admission and so on. (When charts come from duplicating
services they are often in reverse order, with the end of
the hospitalization at the top of the stack.)
3. Once the
medical record is organized, ask that the pages be numbered
in the lower left or right corner.
4. Have the
medical record taken to a copying service and request that
the record be duplicated on predrilled paper (paper with
three holes in it). Have at least two copies made. Set aside
the record supplied by the hospital and keep it in a safe
place.
5. Place the
duplicated copies of the record in three ring binders organized
with the hospital chart dividers.
6. Identify
one of the two copies that have been made as the "working
copy". This copy can be flagged, underlined, highlighted
and written on. The second copy will be used for expert
witness review if the case proceeds further. Since your
set of records and the expert's will be identical, it will
be easy to discuss the case and refer to specific page numbers.
See also:
Analyzing medical records
Summarizing medical records
Medical
records management
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