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LNCtips.com: The Time-Saving Medical Summary

I once worked with a legal nurse consultant who wanted to know how I wrote medical summaries so quickly.  We worked on networked computers and she had access to my files.  One day, she knew that I was working on a medical summary and she periodically checked the file to see what changes I had made during the intervals.   "So that's how you do it!" she said. 

Before I tell you the process I use, I need to spell out one caveat. Experts should NEVER write a report, especially one with their opinions, unless the attorney approves it. In some states, anything that an expert writes, even handwritten notes on a scrap of paper, is discoverable.

The first thing that I do when I write a medical summary is to type the allegations into the report.  I want them front and center so that I can refer to them.  The allegations are the focus of the summary.  If the allegations involve a medical condition that I'm unfamiliar with, I research the condition on the internet. At this stage, the summary looks like the image below. 

allegations

Then I review the medical records, determining which facts I think are important to the case.  While I review the medical records, I start creating the summary.  Before I had a computer, I used to jot down dates and facts on paper, and then I would write out complete paragraphs incorporating each set of facts.   After that I would cut and tape the paper so that the information was in chronological order.  Finally I would type the report on a typewriter.  After I got a computer, I continued this process until one day I realized that I was really creating a medical summary twice - once on paper and again in a computer file.  I eventually stopped jotting any notes on paper, but it was tough for me to stop - I felt like Linus giving up his blanket. However, giving up the paper was a huge time-saver.  Now, I enter information directly into the computer from the get-go without writing anything on paper.  At this stage after entering a couple of facts, the summary looks like the image below. 

start of med chron

As I continue to review medical records,  I enter facts in chronological order as can be seen in the next image, in which I inserted a new fact in between two other facts.  If I have a question about something, I note it in red to look up later, if possible.  I used to write out complete paragraphs, and then cut and paste them in my word processor.  However, I realized that I was adding an extra step by cutting and pasting. Entering facts in chronological order was another huge time saver.

med chron 2

After entering all the facts, I review the rough draft and delete any facts that I realize aren't as important as I first thought. This is another change from how I used to write summaries previously.  At one time, I used to write complete sentences and paragraphs instead of jotting down information.  However, I hesitated to delete paragraphs after I had spent time creating them.  It's easier to delete a few hastily-typed notes than it is to delete a carefully crafted, but later found to be irrelevant, paragraph.

After I go through the deletion process, I fill in the remaining notes so that they're written in sentences, like the image below.  At this point, I try to pick up spelling errors (such as the errors in the spelling of the doctor's unusual last name), although I perform spell and grammar checks at the end of the process as well.  In this example, I also offer an analysis of the actions of the potential defendants. If the attorney had indicated that he wanted a summary only, I would not have included an analysis.

med chron 3

My next-to-the-last step is to write the conclusion and recommendations, the paragraph at the end of the report.  This particular case had several more pages in the medical summary, including Dr. Soudtver's referral to an orthopedic surgeon after the patient's spinal x-ray was negative. The patient finally received his diagnosis of ependymoma after he had an MRI eight months later when he went to a hospital ER for back pain. 

med chron conclusion


My last step is to write the first paragraph, an introduction. The introduction in the medical summary is a summary of pertinent facts and opinions. I have learned that attorneys want to know key information at the start instead of having to read pages and pages of detailed information. I transform this:

allegations

to this:

Intro


Here is what the complete medical summary looks like, minus the few pages that I mentioned earlier and some formatting.

Complete Summary


I think that medical summaries are some of the most time-consuming reports to write.  However, using the technique outlined above allows me to write them in much less time.

Want to learn more about LNC skills for legal nurse consultants? Check out the Archives.

...Katy Jones