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Ed Smith
Ed Smith
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Deciphering Medical Records

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One of the most important tasks an experienced personal injury lawyer does is to organize and summarize his client’s medical records. Without a complete history of the client, it’s impossible to competently prepare the case.

Oftentimes, the doctors chart is a mess. If you cannot decipher the handwriting, our office has found that a telephone call to the doctors secretary an a dreview of the chart over lunch is an idea that sometimes works.

Once the handwriting is deciphered, the next steip is to arrange the records in some kind of logical fashion. In my office, we use Notemap Outlining software ( http://www.casesoft.com/notemap/index.asp) to put the records in order, both chronologically and by provider.

Once the records are input in the outline, its time to look up the definitions of any unfamiliar medical abbreviations. For this purpose we use Pharma Lexicon at http://www.pharma-lexicon.com/ as well as Stanford Hospital’s approved abbreviations at http://www.stanfordhospital.com/PDF/SHCApprovedAbbreviationsupdated051305.pdf#search=%22PNA%20abbreviation%20pneumonia%22.

Another good source for abbreviations is the University of Alabama internal medicine site.