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