LNCtips.com: Medical Summary
In-house and independent legal nurse consultants write medical summaries to provide a narrative report of the patient's course of medical events. Medical summaries can be written in many different ways. There are different schools of thought of what should be included in the summary and how the summary should be formatted. Some narrative summaries simply state the facts, in written form, in chronological order. Those types of summaries are appropriate for a paralegal to create. Legal nurse consultants should include an analysis of the medical/legal issues in their summaries since the RN knowledge base is a major reason that attorneys hire LNCs. The purpose of the analysis is not to dazzle the attorney with in-depth knowledge of the medicine. Rather, the analysis should assist the attorney's understanding of the medicine and how the medicine affects the legal issues in the case.
Before you create any written work product, you should review the Plaintiff's allegations and any other pertinent documents. Your medical summary and analysis will be a review of the medical records as they pertain to the Plaintiff's allegations. The merit of each allegation needs to be addressed.
If you are comfortable with a particular format for medical summaries, by all means use it. But if you're not sure how to write a summary and analysis, here are some formatting tips for creating the document. These tips are a combination of formatting from business reports and APA style.
* Use an easy to read font. Calibri, Verdana, Arial, Helvetica and Times New Roman, size 10 to 12 are usually good choices.
* Use a footer with the words CONFIDENTIAL ATTORNEY WORK PRODUCT centered on the bottom.
* Insert page numbers into the bottom right corner.
* Use full justification for the document.
* Use 1 to 1.5 inch margins on the right and left sides of the paper.
* Center and bold the heading for the name of the summary as shown below:
of Plaintiff v. Name of Defendant
File or Claim Number
Medical Summary and Analysis
* Single space paragraphs.
* Insert one additional line between each paragraph.
* Indent the first line of each paragraph.
* Use two spaces between sentences. With modern word processing software, only one space between sentences is truly needed. However, law firms are traditional organizations and tend to use two spaces.
* Use headings to organize your summary. The introductory paragraph is self-explanatory and doesn't need its own heading.
* Use the following guidelines for numbers:
* Write out numbers from zero through nine. Numbers 10 and above are generally written as numerals.
* Do not start or end a sentence with a numeral.
* Do not write out metric units of measure when they are preceded by a number; they should be abbreviated and in lower case (for example, two kg, 30 cc, 12.4 cm).
* Write out all other units of measure (for example, inch, pounds, feet, ounces).
* Do not use periods with acronyms or medical abbreviations (for example, use COPD instead of C.O.P.D.).
* Write out all medical abbreviations the first time they are used. If you plan on using the abbreviated medical term later in the summary, write the abbreviation within parentheses after the term. For example: Mr. Smith had a cerebral vascular accident (CVA). Because of the CVA, he had difficulty ambulating.
* Use a lower case "s" (without the quotes) for plural abbreviations (for example, Mr. Smith had two IVs infusing.) Notice that the example did not use an apostrophe. Use of an apostrophe before the "s" indicates the possessive (for example, The IV's contents included potassium.)
* Limit the use of medical abbreviations. The summary should not look like a medical chart.
* As you identify names of organizations, physicians, and other providers, list them in a separate Treater List. This will help the attorney decide which additional records to obtain and whom to depose.
When composing the report, consider these guidelines:
* Unless your name will be typed onto the report do not use the word "I" in the report or refer to yourself as "the writer". Your report may be filed by the attorney after its initial reading and then not read again until much later. Unless your name is on the report, the attorney may not remember who authored the report. Or the case could be transferred to a different attorney who will wonder who "I" or "the writer" are.
* Write the report as if the reader is intelligent but has limited knowledge of medical terms and conditions. Describe terminology and conditions in language that a layperson can understand. Do this even if the attorney has an excellent grasp of the medical terms and principles. Again, cases do not always remain with one attorney and the next attorney might not have the same grasp of medical conditions that the first one had.
* When describing items with metric measurements (and the items are important to the case), indicate the non-metric equivalent in parentheses. Many people in the United States don't have a grasp of the metric system except, perhaps, for the metric liter because Coke and Pepsi come in two-liter bottles. Most people, including attorneys and jury members, find it helpful when non-metric equivalents are provided for size, speed, volume or weight when those are presented in metric measurements. An example is, "The wound measured 8 cm long by 6 cm wide (3.1 inches long by 2.4 inches wide)." Comparing measurements to common items is also helpful. An example is, "The rash measured 2.5 cm in diameter which is about the size of a quarter." Of course, if the measurement isn't important to the case, it's not necessary to convert it.
* If the medical records are Bates stamped, consider including the numbers in your report. It may feel cumbersome to identify the Bates stamp numbers but they can assist the attorney and nurse in locating information. Put the number in parentheses at the end of the sentence describing the findings in the particular medical record.
* The first paragraph of the summary is an introduction or overview of the case citing key facts. Also identify each set of medical records reviewed.
* Make the second paragraph a summary of the allegations and the nurse consultant's determination of the merit of the allegations. This is a key paragraph because it provides the reader with a road map, providing direction to the reader for the rest of the summary and analysis.
* The third paragraph can be composed of a bulleted list of the patient's diagnoses and information about those diagnoses.
* The fourth paragraph (and as many subsequent paragraphs as needed) is a brief narrative chronology of key events in the case.
* The analysis may be identified by its own heading or incorporated throughout the report, whichever is more logical for the case. An initial review of a Plaintiff case should always identify whether the LNC believes that an expert will find the case to have merit or not.
* You should add relevant medical information obtained from journal articles and internet research in the summary either under its own separate heading or incorporated under other headings.
* Journal articles can be referenced as foot notes.
* Your last heading should identify recommendations as they relate to medical records, type(s) of expert witnesses needed, and specific fact witnesses which may need to be interviewed. If you are an independent LNC, the recommendation section can also be used to suggest additional services. For example, "The records of ABC hospital don't support the plaintiff's allegation that the nursing staff ignored him. A more detailed Touch Chart would illustrate the times that staff interacted with the plaintiff. If you want this additional report, please contact XYZ Consulting for a personalized report."
While the summary and analysis report has specific components and a specific order, the actual writing of the report doesn't have to be in the order of those components. You can review the medical record and type your observations in a rough draft as you review each page. After the facts are identified, you can fill in the report and format it. The two most important paragraphs are the introduction and the recommendations so you may want to type them last.
For a mini example of how to write the report, see The Time-Saving Medical Summary.