Important Things To Look For When Reviewing Medical Records

Bruce Burk

Tampa, FL ( – Reviewing medical records goes hand-in-hand with managing a workers’ compensation claim. However, while reviewing hundreds of pages of medical records can get pretty boring, doing so can be highly relevant to the claim.

Reviewing medical records can be a daunting task. In cases involving older dates of accident or catastrophic injuries, the sheer quantity of medical records can be difficult to manage. This is why it is a good idea to create chronologies or summaries of the medical records to keep track of what the records contain.

Medical records are often sent in response to subpoenas or medical records requests. When the come, they are often out of order and combined with billing records. Many of the documents sent do not contain any valid information and it’s important to be able to distinguish what is relevant and what is not.

The main thing to look for is the dictations from the doctors. Next, you want to look for any diagnostic testing such as MRIs, EMGs, CTs, ultrasounds, psychiatric evaluations, etc. These are the documents which help narrow the issues in the claim and contain the doctor’s actual opinions.

Doctors are supposed to follow the state’s specific workers’ compensation documents which contain information such as work restrictions, medical recommendations, maximum medical improvement status, and opinions regarding whether the treatment is related to the industrial accident. However, sometimes doctors forget to do this and you have to put together the information from the doctor’s dictations.

As for the content of the documents themselves, there are several important things to look for and document. First, you want to look at who created the dictation. Sometimes, the claimant sees people other than the specific authorized doctor, such as a physician’s assistant or a nurse practitioner. The license level of the person giving the opinion can affect the weight and credibility of the opinion.

Next, you want to look at the history. If you are aware of prior accidents or medical treatment the absence of disclosure of the same can indicate the claimant may not have been truthful with their doctors. This section will also contain possible chronic conditions that could be relevant to the claim and the value of the future medical exposure.

You should also look for the progression of the claimant’s complaints. One should track whether the claimant is getting better or worse, especially after treatment such as surgery or injections.

Moreover, the medical records can often indicate whether the claimant is working and whether they are having any issues with work. This can be a possible indication of whether there will be any indemnity exposure on the file.

Most importantly, you should look for any prescriptions for significant medical treatment and any referrals to different specialties. This could trigger a responsibility to authorize additional medical treatment or investigate whether the medical care is related to the accident. Medical records should be periodically requested from both authorized and non-authorized doctors to have a compete understanding of the claimant’s medical care.

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