Many of your cases likely hinge on medical information, but how you obtain, vet, and present those records is vital as well. Not all medical records are courtroom-ready documentation; the advent of electronic health records (EHR) means that patients’ medical records and healthcare organizations’ legal medical record (LMR) are not identical. Understanding why they’re different and what that means for your next case can help you streamline administrative burden for yourself and your team while ensuring your clients receive a fair settlement.
Why isn’t a legal medical record the same as a medical record?
Medical records and courtroom-ready documentation are two distinct documents and serve fundamentally different purposes. The former is designed to provide thorough information to patients and their healthcare teams across practices and providers. The latter is the specific information an organization provides for evidentiary purposes. How the medical record and LMR will differ depends on how each organization defines the LMR, but, generally, expect it to be more focused and less detailed than the medical record. For example, the LMR might contain a summary of diagnostic findings while the medical record lists them in full and includes supporting imagery, such as X-ray, CT Scan or MRI, as explained here. The information shared with you will be tailored to the scope of your request, so the first step is understanding how best to obtain an LMR that covers everything you need.
Knowing how to ask for a legal medical record can save you time and get the right information
If your case hinges on past documentation, the LMR request process is foundational. Get the scope of your request right – if it’s too narrow, you risk not including key information. For example, you may need to ensure you have access to actual imaging or test results rather than a summary of results. Conversely, a request that’s too broad can generate resistance from healthcare providers navigating HIPAA regulations.
Making sure the basics are covered is crucial as well. Make sure to detail the information you need, the date range, the provider from whom you’re requesting the records, the person or firm receiving them, why you’re asking, the expiration date of the request and a notice of the patient’s right to revoke consent, according to this article. Taking these steps will set you up for success in the courtroom and avoid delays. Know all federal and state regulations that pertain to your request.
Review and presentation: Where the legal medical record transforms from document to catalyst
Once you have the LMR, both review and presentation offer opportunities to not only ensure accuracy and compliance but also ease of reading for everyone in the courtroom. Yes, this is your last chance to check information and dates and verify, redact as necessary and double check that everything complies with relevant jurisdictions.
It’s also your chance to look at the LMR and give a closer look at what information should be highlighted and how best to do that. Well-formatted records laid out in a clear order and in consistent formatting make it simpler to get a clear overview of the evidence. Beyond that, think about how you want to frame the most important points. That might include medical imaging or statements from healthcare providers.
When possible, seek out healthcare providers familiar with the legal system
Obtaining, reviewing and presenting an LMR in court is a complex process at each step. If you are able to refer your patient to a healthcare provider who also has expertise in producing courtroom-ready documentation, you can reduce delays and be sure of receiving records in presentation-ready format. At Nexus Triage, we’ve worked with dozens of prominent law firms and their clients to provide a full diagnostic report outlining diagnoses, impairment level, and recommendations for further care and evaluation. We share that with you and your client within 72 hours, rather than the 30 days that most jurisdictions give healthcare practices to respond to a medical record request. Our HIPAA-compliant assessment is conducted via telehealth, so your clients can complete it from any location, meaning they – and you – can streamline the case and be assured that all injuries (including those invisible on standard diagnostic tests) are fully documented.
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