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Specifying the Format of the Medical Records based on a chapter by Peter Berge JD, MPA, PA

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Specifying the Format of the Medical Records based on a chapter by Peter Berge JD, MPA, PA

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Medical records on CD- a mixed blessing

Medical records on CD- a mixed blessing

Records are obtained by plaintiff’s counsel prior to filing a medical malpractice suit. Ordering an extract of the medical record (typically containing information such as the admitting history and physical examination, discharge summary and laboratory results) is rarely appropriate in medical malpractice cases. Normally, complete records should be requested.

Med League was recently asked by a client why she preferred to read paper records over records that have been scanned. The attorney’s perception was that he would save money if he supplied a disk with medical records. He did save money- on the shipping costs. The decision of whether or not to request records in digital format, such as scanned records on CD-ROM (if available), is based in part on the degree of sophistication of the records. Typically, medical records are simply optically scanned and stored in a portable document format (PDF) image file. As such, the reviewer cannot search for text, and must page through each screen to find the desired parts of the chart. If the file is large, and is not numbered and indexed as to content and location, it can be cumbersome to work with and review. Some reviewers find it easier to print out and work with a paper copy, which allows flagging and annotation; this results in a standard paper record. This is particularly true when records are voluminous. Everyone’s definition of voluminous may be slightly different, but to me, voluminous records fill a copy paper box.

Of course, charts scanned on disk require very little storage space (until they are printed), are easily reproduced by copying the disk, and may provide individual files that can be sent by e-mail or transported using a usb drive.

If the scanned records happen to be indexed, allowing the reviewer to jump from section to section (e.g., progress notes to laboratory results, medication records to operative reports), then the digital format is extremely convenient for review. But scanning a batch of unorganized records is often a waste of time. Remember, it is more economical to present the reviewer, whether that person is an expert, a consultant, or an attorney, with information that is organized in a logical way.

Modified from  “Attorney Use of Medical Records in a Medical Malpractice Case” from  Medical Legal Aspects of Medical Records, Second Edition, 2010.

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