Prepare Medical Summary for Personal Injury Litigation Cases

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This article is part of the “How To” blog series in which I offer practical tips that paralegals can use to support attorneys before, during and after litigation. Subscribe to get updates so you won’t miss the next article in the series!

Earlier in the series, we covered how to request medical records in 5 simple steps as well as organizing and indexing records once you receive them in office.

Now that you have the records organized, let’s discuss the next step you should take before you file the documents away.

Prepare a medical summary to outline the client’s injuries and treatment received from his or her physician. A well-crafted summary will save the injury attorney you’re supporting considerable time when it comes to document review.

There is no “right” way to prepare a medical summary, but here are 10 key components you must have:

1. Client (Patient) Information

Include the client’s full name and date of birth as well as the case style and your firm’s file number. (I do not recommend including the SSN on this document.)

2. Medical Provider Information

It is common for a person to seek treatment from multiple medical providers. Make sure you identify the physician, hospital or facility whose records you are summarizing.

3. Date of Injury and Date of Visit

When reviewing medical records, it’s important to know the symptoms and treatment that took place before and after the injury. You also need to be on the lookout for any lapse in medical treatment. The DOI tells you when the injury occurred and in most instances, the first onset of pain and other symptoms. The date of visit (whether it’s a single office visit or an extended period of care) should be included in the summary.

4. Chief Complaints

State the reason for the client’s visit to the doctor. What were the chief complaints described by the client?

5. Present Medical History

This is where you will summarize when and how the injuries occurred, describe the symptoms, and list medications (if any) the client was taking at the time of the office visit. You also want to include any physicians that treated the client for the present injuries before the subject office visit (i.e. hospital emergency room).

6. Past Medical History

You want to make sure that the attorney and every team member is aware of any pre-existing injuries, illnesses or medical conditions. You should include information that is related (and unrelated) to the present medical history.

7. Physical Examination

It’s important to have a clear picture of the extent of the client’s injuries to truly understand the pain and suffering endured on the road to recovery. Summarize the results of any spinal or neurological exams, range of motion or orthopedic tests performed.

8. Diagnostic Studies and Findings

Were any xrays or CT scans done during the office visit? Any MRI’s scheduled? Include the date on which the xray was taken and the findings detailed on the report. If the physician requests additional studies, include that recommendation in the summary – and set a tickler to follow up until it’s done. (We’ll discuss setting up tickler systems in the near future.)

9. Diagnosis / Prognosis

The severity of an injury is often revealed in the diagnosis. In some records, it’s referred to as the “impression.” Include the diagnosis in the medical summary as it will play a significant role in future treatment recommendations. If the physician offers an opinion as to prognosis, you should add it to the summary as well.

10. Treatment Recommendations and Prescriptions

In this section, list the doctor’s recommendations. Was the client referred to a specialist or to physical therapy? Was a MRI or other radiology test ordered during the client’s visit? If so, provide a brief summary of what was recommended. Be sure to include a list of any medications prescribed to the client.

There you have it… 10 must-have components of a medical summary!

Need help getting started? Download my Example Medical Summary form.

What’s Coming Up?

Next in this blog series, I will share practical tips you can use to create medical chronologies and timelines. You don’t want to miss it so make sure you subscribe to receive updates!