A Guide on How to Summarize Medical Records Effectively

Drilling down to the factual narrative that you need to extract from medical records can feel like spinning straw into gold. These records are often full of patient information and clinical details. Vastly different reporting formats, levels of detail, jumps across time, and a truly phenomenal amount of pages—these are just some of the factors that make it a challenge.

The gold lining is that advancements in technology have made summarizing medical records much more manageable. Learn how to summarize medical records efficiently for legal cases below.

Key Steps to Summarizing Medical Records Effectively

The first step in reviewing and organizing medical files efficiently is understanding the plurality of “records.” For the vast majority of individuals, there is no single location that contains all records in a unified state. 

Instead, you may find records in various levels of detail from sources including: 

• Hospitals, clinics, and community health organizations
• Doctors, nurse practitioners, and other providers (or their practice groups)
• Medical testing and diagnostic centers
• Individual specialists and technicians performing or consulting on tests or procedures
• Ambulance providers
• Pharmacies and medical supply providers
• Home health care providers
• Rehabilitation, nursing homes, and assisted living facilities
• Physical, occupational, and other therapy providers
• Clients/patients directly

Each different provider or facility (and time frame) may have uniquely structured records. Reports about patient history can often be scattered across different documents, requiring thorough examination. You may also need to specifically request components like practitioners’ notes vs. patient-facing visit summaries. 

While summarizing medical records involves discovering details that are new to you, it’s still helpful to identify goals and targets before you begin. As you review: 

• Record each file in a database with useful summary information
• Assemble timelines of connecting events and dates
• Tag files with relevant keywords for cross-referencing
• Identify important details including practitioner, facility, diagnosis, treatment, and complaint
• Maintain accurate records and comply with privacy and security protocols

Best Practices for Medical Record Summaries

You’ll need to understand the typical structure and components of different types of medical records prior to a thorough review. To get the best summary results: 

• Decide whether to offer a chronological or problem-based summary format
• Use clear and concise language helpful to legal and insurance professionals
• Be mindful of potential bias within the files while summarizing them
• Seek expert advice to clarify test findings, treatment options, and other information
• Identify inconsistencies, including missing files and findings

Leverage Technology for Effective Medical Record Summarization

Medical record organization and summarization require time, attention to detail, and familiarity with a unique professional language and protocols. Luckily, using AI medical record tools can enhance both accuracy and speed of medical record reviews. AI assistance with medical record summaries has improved results while also reducing time and costs. 

However, AI-generated record summaries should be dynamic and actionable. Make sure they include:

• An abstract with an overview of conditions, treatment details, outcomes, and impacts
• Key sections, such as conditions, events, treatments, practitioners, and timeline 
• Identification of key medical records, discrepancies, and potential liability issues
• Hyperlinked table of contents 
• Comprehensive capture of unstructured data elements (for instance, images) in addition to text

How Outsourcing Medical Record Summarization Improves Efficiency

The decision to outsource medical records is often based on a mix of resource and risk management. When it comes to medical records, firms often find that there are benefits in working with professional legal support teams in both areas of consideration. 

Specifically, medical record experts can: 

• Organize and summarize records according to client needs
• Monitor each institution’s records request process and requirements
• Provide a seamless experience from initial request to final reports
• Ensure record management adheres to cybersecurity protocols
• Stay on top of shifting HIPAA and overlapping health data regulations

Ensuring Compliance and Confidentiality in Medical Record Summaries

Proper summarization of medical documents preserves patient privacy and data integrity. The American Bar Association advises attorneys to consistently follow HIPAA regulations on “the safekeeping, sharing, and enforcement requirements for health care providers and others who handle ‘protected health information’ (PHI).”¹

Best practices on following HIPAA privacy, security, and breach violation rules include: 

• Limiting access to PHI and training anyone who handles it on HIPAA compliance
• Recording and tracking individual access to all PHI
• Using security protocols (for instance, encryption and password protection)
• Maintaining PHI as single-source content (i.e. no downloads or emailing)

HIPAA compliance for law firms isn’t a simple matter, and violating it either willfully or accidentally comes at a significant cost. Civil penalties imposed by HHS’ Office for Civil Rights rise as high as $2,134,831 per violation, and criminal penalties range from $50,000 to $250,000 per violation, plus up to 10 years in prison.²

Final Thoughts on Summarizing Medical Records Effectively

Extracting the details you need from medical records and providing efficient summaries at each stage of the legal process is key to streamlining case analysis, negotiation, and trial preparation. To get the most effective and efficient results, leverage best practices, AI integration, and support partners who specialize in medical records management.

For nearly 30 years, U.S. Legal Support has offered industry-leading litigation support services, including medical records retrieval, organization, and analysis. Today, we also offer innovative AI-powered medical records summarization to identify key details, maximize efficiency, and reduce costs.

Contact us to learn how we can help with your medical records summaries and other legal support needs.

Sources: 

1. American Bar Association. HIPAA for the Family Law Attorney. https://www.americanbar.org/groups/family_law/publications/family-advocate/2023/winter/hipaa-family-law-attorney/
2. HIPAA Journal. What Happens if You Break HIPAA Rules? https://www.hipaajournal.com/what-happens-if-you-break-hipaa-rules/

Julie Feller

Julie Feller is the Vice President of Marketing at U.S. Legal Support where she leads innovative marketing initiatives. With a proven track record in the legal industry, Juie previously served at Abacus Data Systems (now Caret Legal) where she played a pivotal role in providing cutting-edge technology platforms and services to legal professionals nationwide.