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I Organized The Medical File A Different Way. It Made All The Difference!

Aug 15, 2016 | Nursing News | 0 comments

Dear Nightingales and Friends,

I was talking with an attorney client and paralegal about the various ways to organize medical records. He had mentioned, “Last time you organized records, it was by medical category. Why did you do it differently?”.

Some clients prefer medical records organized the same way no matter how many pages or providers.
Some clients have liked medical records organized differently depending on how many pages.
Some clients like to keep the records organized according to the Bates numbers and don’t want them changed. Some don’t care about the Bates number.
Some clients need to coordinate medical summaries with chronologies or audit spreadsheets to the medical records and need to go from one to the other as fast as possible in the courtroom.

You get used to doing it one way as office protocol.

I know I have sent clients records according to all of these ways.

It is not the same to review a case with 80 pages and one with 6000 pages.

The goal is and should be visualization and quick access to the final source – which is the medical record.

When I organize files, I consider 3 usual options:
1. Medical Records File (like a hospital record by category) – this takes more time since the files have to be re-organized,
2. Provider File – this method is the simplest and easiest since records are usually delivered like this from the retrieval company or paralegal
3. Chronology File [this takes he most time] – since all the files need to be merged to create a file by date/time

Any reorganizing of the files changes the ease of access – since the file is no longer organized by Bates numbers.

The new file can be re-Bated with new numbers – but consider – that you are the only one with the new Bates product – unless you copy/distribute it.
I always think of 4 things when I organize files:
1. Who is reading it? What do they need? How do they need to visualize the file: timeline, subject, ease?
2. What is the quickest way from the Report: chronology to the Resource document. Bates? Provider? Date? Category?
3. What is the volume of files? Volume means Bates may be easier – but it all depends on #1 and #2.
4. Who else will need to access the file information? Re-organizing and re- Bates the files means that unless you re-distribute the new organization everyone else will have a different set – especially of Bates numbers.

When I review a case with a client, we will frequently go through the binders and connect the medical record pages to the chronology to the medical summary and analysis to the discussion. Sticky notes start flying tabbing places to remember with bright colors to flag important references. Notes in pencil on the medical records pages.

Ultimately, it is you that needs to read, brainstorm, organize and depend on the binder file. It is yours to write in, highlight, bend, etc.

It is meant to be your working copy. You have more – I will enclose a copy of the Adobe PDF medical record and report files on a flash drive for you to print as many times as you like.
And here’s a thought – it is always possible to make you a separate folder of the records in Medical File order. It makes 2 binders – one in Provider File and one in Medical File.

It all depends on how you need to visualize what happened and how fast you want to be able to move between reports, resources and the medical record.
And each case can be different.

I look forward to talking with you about how I can assist you in preparing your medical records in coordination with a medical chronology and summary analysis in the best possible platform for you and your team to use for your case.

Helping You Find The Answers

Audrey Friedman RN

[Original Post 08/15/2016]

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