LNCtips.com: 2 Steps to Acquire an Abstract
A medical record abstract is an extraction of pertinent medical records related to patient care. Plaintiff attorneys often use abstracts as screening tools. These attorneys don't want to invest money to obtain a complete chart until they're sure that medical malpractice has occurred. With voluminous electronic records, some defense attorneys want abstracts too so that they don't have to wade through tens of thousands of pages of records. However, not all abstracts are created equal, and there's an art to acquiring the correct kind. Here's how to do that in two steps.
Because each medical malpractice case is different, the information that the attorney needs may not be included in a provider's usual abstract. In addition, abstracts differ greatly from institution to institution. Here are seven different definitions of an abstract from seven different providers.1) Anything up to 50 pages. This was from a physician practice.
2) Immunizations, two years of office visits and lab information, and five years of radiology and diagnostic reports. This was from a pediatric practice. The following ones are from inpatient settings.
3) Dictated physician reports such as cardiology, medical imaging, and pathology.
4) Discharge summary, operative notes, and diagnostic testing.
5) History of illness, discharge summary, test results, medications, hospital course, and discharge diagnosis.
6) Discharge summary, history and physical, lab, pathology, operative reports, procedure notes, radiology reports, problem lists.
7) Emergency room records, radiology reports, laboratory.
It's apparent from the list above, that if you just request an abstract, you'll receive different kinds of information, depending on the institution. Therefore, your first step in acquiring an abstract is to determine the type of information needed. This will entail a conversation with the attorney or clients. For example, if the case involves a pediatric inpatient who received an inappropriate medication, you will need nursing notes, physician orders, and medication administration sheets for the date of the incident and perhaps for a few days before and after the incident. This isn't information that's normally included in an abstract. Of course, you'll want some of the "usual" information, such as the discharge summary, as well.
If the institution has a pre-printed authorization form, your second step is to read the authorization and determine if the abstract includes the information that you need. If not, add it and have the client (the patient) sign it. If the law firm uses its own authorization form instead of the institution's, make sure that the form includes exactly the information that you need. If you're working for the defense, the firm most likely will need to issue a subpoena, not an authorization. However, you will still need to ensure that it specifies the information that you need.
That's it! Complete these two steps and you're on your way to getting an abstract that's tailored to the case.