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A good medical summary for a personal injury case is a concise, accurate chronology of the medical care provided to the injured plaintiff before and after the event. It should be written to be easily understood by a layperson. Experienced legal nurse consultants prepare RPC medical summaries. They give attorneys, consulting physicians, other consulting clinicians, vocational consultants, and life care planners the historical information they need as a basis for their opinions. They are important components of our vocational assessments and life care plans.
A medical summary for a personal injury case should be based in part on all the pre-event and post-event medical records the nurse can obtain from the plaintiff’s past and current medical providers. With the help of the responsible attorney, the summary writer begins by gathering all available documents, not just medical records and billing records, but other documents that may lead to other medical records:
- Records of first responders to the injury scene, whether police, fire, or EMS. In a motor vehicle accident, the police report details the vehicles involved, the direction of impact, and the relative position of the person(s) involved. It includes information on the use of safety devices (e.g., helmets, seatbelts, or airbags), vehicle damage, demographic details, and often a brief narrative. Similarly, the first report of injury for a work-related injury may have the conditions of the area where the event occurred, what the injured person said about the event, bystanders’ witness statements, and pertinent details about the plaintiff’s condition when help arrived.
- Employment records may contain results of pre-employment physical examinations and note workplace injuries, leading to workers’ compensation claim files. They may also lead to medical records through the employer-sponsored health plan.
- Claims histories of health insurers
- Military records may contain results of medical examinations, service-related injuries, and disability ratings at discharge.
- Workers’ compensation files may contain detailed information on past injuries, past medical care, activity restrictions, releases to return to work, and impairment ratings.
- Social Security Disability claim files may contain physician reports describing a person’s disabilities.
- Police reports and correctional records may indicate injuries noted at the time of arrest or that occurred while incarcerated.
Obtaining these records can take considerable time and the summary writer should work closely with the attorney to request records voluntarily or through discovery.
The medical summary should describe diagnoses, treatment, and prescriptions in the order they occurred. The summary writer should include any clinical opinions or recommendations found in visit notes, independent medical examinations, work status reports, or other clinical reports. The summary writer should include all items whether related to the injury that is the subject of the litigation or not. For imaging studies and tests, the summary writer should obtain the images and not just the report by the physician or technician.
The summary writer need not have an entry for each medical record. For example, where a course of physical therapy may generate notes for each visit, it is unnecessary to have an entry for each visit. It may be more useful to note the plaintiff’s condition at the beginning of therapy, the therapy goals, the modalities used, the plaintiff’s condition at discharge and the achievement of therapy goals.
RPC can provide samples of medical summaries properly redacted, upon request. For more information on RPC or to discuss a case, contact Roy Bourne, Operations Manager, at 512-371-8026 or rbourne@rpcconsulting.com