Organize and Index Medical Records in 6 Simple Steps

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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!

organize medical records In cases involving serious injuries, it is not unusual for a client to have multiple medical providers. You will need to request medical records from each to get a full understanding of the extent of the client’s injuries and treatment plan.

If pre-existing injuries are involved, you may need to request those records as well.

As you start to submit medical requests, the records will arrive in office. In a matter of days, you can find yourself sitting in front of stacks of records. As a personal injury paralegal, it is your responsibility to make sense of it all.

What should you do? Do not simply file the records away until the client has been released from treatment and you are asked to prepare a demand letter or send the records to an expert witness. That would be asking for trouble.

Instead, organize the medical records and prepare medical summaries as the documents are received. If your firm is totally paperless, you may already have an effective document management system in place. But if you are in the process of converting to a paperless system, these instructions will show you how to organize the records before you scan and save them on your computer.

Here are 6 simple steps you can rely on:

Step 1: Separate the records
You can use index dividers to separate the records you receive from each medical provider. I like to use Avery’s Ready Index Reference Dividers, especially if the attorney wants to create a medical records notebook for the case.

The dividers are sold in sets of 5, 10 and 15 tabs (possibly more), and include a blank table of contents you can customize and run through your printer.

Step 2: Break each tab of medical records into the following subsections:

Progress notes
Nursing notes
Xrays, MRIs and other radiology reports
Lab results and reports
Referrals and prescriptions

This step is optional. Some attorneys like to have the records for each medical provider divided into subsections and others do not. It’s a matter of preference so see what works best for the attorney you support.

Step 3: Put the records in chronological order with the most recent on top.

Step 4: Prepare a table of contents for the medical records index.
A blank table is included in the package of index dividers I recommend in Step 1. You can use MS Word or Avery online to prepare the table of contents. If you are using Word 2007, you will need to:

1. Select “Mailings” and then “Labels”

2. Select “Options” and use the drop down to find your label number.

3. Select “New Document,” customize and print the table of contents. That’s it!

Step 5: Scan and save a complete copy of the organized medical records on your computer.

If you are working in a law firm, check the copier to see if it has a page numbering option. If so, you can use it to bates number the bottom of each document as you run it through the feeder.

Step 6: Use software to bates number the medical records.

Bates numbering (also known as bates stamping) is when you add a number, symbol or any other information to a document to label and identify it.

In litigation, legal professionals use bates numbering during document production. This makes the process of reviewing, summarizing and referencing records less of a headache.

A bates stamp can be as simple as “Plaintiff – 001” or more detailed. You decide. I use CutePDF Professional (the best alternative to Adobe I have found) to bates number any document. Here’s how it works:

Select “Header and Footer” from the menu.
Insert the bates stamp in the footer area. You can use the tag to automatically number the pages.

Select “OK” and take a look at the document’s footer. You’re done!

When it comes to organizing stacks of medical records in a serious injury case there are many ways to get it done. The system you put in place really doesn’t matter as long as you organize the records early. This will save you, the attorney and every legal professional working on the case a great deal of time.

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Photo credit: nigelmaine

This article is part of the “How To” blog series of practical tips for litigation attorneys and paralegals. Subscribe to get updates so you won’t miss an article!

As you start to submit medical requests, the records will arrive in office. In a matter of days, you can find yourself sitting in front of stacks of paper medical records. As a personal injury paralegal, it is your responsibility to make sense of it all.

What should you do? Do not simply file the records away until the client has been released from treatment and you are asked to prepare a demand letter, summarize or send the records to an expert witness. That would be asking for trouble.

Instead, develop a plan for managing, organizing and indexing medical records as the documents are received. If your firm is totally paperless, you may already have an effective document management system in place. But if your firm is in the process of converting to a paperless system, these instructions are for you.

Here are 6 simple steps to take to organize and index medical records before you scan and save them to your computer.