I have been digging through medical records in search of hard to find data since my first post college job. As a resident and then as an attending physician, I found that an accurate history often included careful review of a patient’s previous admission records. Now, as a medical consultant for a legal firm, I spend a large portion of my work day going through records. Deciphering handwritten notes and learning to navigate the endless pages of the new electronic records takes patience and attention to detail but the effort pays off. When reviewing a medical chart as part of the discovery process, I have found five tips to getting the most from the material.
1. Start by having as much knowledge of the underlying disease process and treatment as possible. Whether it is a myocardial infarction or laparoscopic appendectomy; you will find it easier to look for the information you need when you are familiar with the process.
2. Be patient when learning the format of electronic health records (EHRs) provided to you. There are no uniform standards between health care entities. Formats for recording findings and notes will vary widely. Finding useful observations in nursing or other ancillary providers’ notes may take a lot of painstaking reading especially in records that often now include hundreds of pages.
3. Concise timelines can be used when timing of events is crucial to understanding the order of events which then can be compared to appropriate standards. Useful information may be hidden in ancillary service notes.
4. Check out the nutritionist’s notes as well as any rehab or social work services. Don’t just stick to the obvious providers. A complete set of records is important. Be as complete as possible. Don’t stick with just the records of the incident in question.
5. Get records from before and after the event and from every provider possible. The more records, the more likely that information that could turn the tide in your client’s favor will be found.