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Organizing medical records

Organizing medical records

Are you tired of continually trying to find information in a medical record in a big stack of documents like those shown on the left? (Yes, these are from one case!) ?

big-stacksm-112x300Organized medical records help you and your expert quickly locate information in the record. This makes it easier for the expert to review the material. Organized records are a great aid during a deposition, and increase the expert’s confidence that he or she will be able to rapidly locate requested material.

We see all kinds of medical records come into our office, from the meticulously organized to the totally unorganized. We follow this system for handling your medical records.

1. We use hospital or nursing home 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.

2.We 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, each section is 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.) We use our nursing knowledge to identify pages that are missing, out of order, and updated and make every effort to correctly place the page.

3. Once the medical record is organized, we offer an optional service of numbering in the lower left or right corner.

4. Some of our clients request an organized set to be duplicated and returned to them. This permits the attorney and expert to have identical sets and eases communication about specific pages in the record.

5. We place the duplicated copies of the record in three ring binders organized with the hospital chart dividers.

6. 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.

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