Medical records can run to hundreds or even thousands of pages, particularly in complex clinical negligence and personal injury cases.
The information you need may be there, but finding it can be another matter.
Records can arrive from multiple healthcare providers, cover many years of treatment and contain duplicate documents, different formats and computerised records that are difficult to navigate.
So, how can you make medical records easier to review?
Start with properly organised records
Before reviewing the medical evidence, it helps to make sure the records themselves are properly organised.
Medical records can arrive from several sources and at different stages. Without a consistent structure, finding a particular consultation, investigation or period of treatment can become unnecessarily time-consuming.
Sorting and pagination can bring order to the records by organising documents into a logical structure and applying consistent page references. This gives everyone working on the case the same organised set of records to work from and makes it much easier to return to specific information later.
Remove unnecessary duplication
Duplicate records can add significantly to the size of a medical bundle.
The same document may appear several times across a disclosure, making the records look more extensive than they actually are and creating additional work during review.
Identifying and appropriately managing duplicate documents can make the final set of records more manageable and reduce the amount of unnecessary information that needs to be worked through.
Create a clear timeline
Even when records are organised, understanding the sequence of events can still require considerable review.
Important information may be spread across GP records, hospital notes, investigations, referrals and correspondence from different points in time.
A medical chronology can bring relevant events together into a clear timeline, making it easier to understand what happened and when.
Rather than replacing the underlying records, the chronology provides a structured way to navigate the medical history while retaining references back to the original documents.
Make computerised records easier to navigate
Computerised medical records can present a particular challenge.
A single record may contain a large number of entries covering appointments, prescriptions, test results, referrals and other information. Finding a particular event can mean working through a significant amount of material.
Tools that allow records to be filtered by information such as dates and keywords can make this process more manageable.
Within MedBrief Insights, our CER Index allows users to navigate computerised medical records more easily by filtering the information they need, helping narrow down a large record before reviewing the relevant entries in more detail.
Search for information, not just words
Keyword searching can be useful, but it isn’t always enough.
The same medical event may be described in different ways across the records, and the exact terminology you’re searching for may not appear in the document.
Technology can provide another way to work with the information. With Ask Alex, our AI assistant within MedBrief Insights, users can ask questions about their case in everyday language. Instead of manually searching through the records to establish when a claimant was first referred to a particular specialist, a user can ask Alex the question directly.
Alex provides an answer based on the case documents and includes citations, allowing the user to return to the original source and check the information for themselves. This can make finding information quicker while keeping the user in control of the review.
Focus on the key events
Not every page within a medical record will have the same relevance to the issues being considered. Identifying significant events can help provide a clearer view of the case before moving into more detailed review.
MedBrief Insights’ Key Events feature brings significant events from across the case into a timeline, helping users see the sequence of important information more easily.
This can provide a useful starting point for understanding the wider medical history and identifying areas that may need closer attention.
Consider when clinical input could help
Sometimes the challenge isn’t finding the information. It’s understanding its clinical significance.
An Early Case Assessment can provide clinical input at an early stage of a claim, helping identify key clinical issues within the records and areas that may require further investigation. This can help legal teams focus their review and make more informed decisions about the next steps in a case.
Making medical record review more manageable
Making medical records easier to review isn’t about reducing the amount of evidence available. It’s about making that information easier to navigate and use.
Properly organised records, consistent pagination, clear chronologies, clinical input and the right technology can all help turn a large volume of medical information into something much more manageable.
At MedBrief, these services and tools are available through one secure platform, helping legal teams move from navigating the records to finding and understanding the information they need.