One of the key duties of a paralegal in the area of personal injury litigation is reviewing an individual’s medical records. In fact, in almost every aspect of law, a paralegal is asked to review medical, employment or scholastic records at some point in time. These records are important in determining the value of a case. In most instances, these very records serve to substantiate the claim of injuries by a plaintiff or, in the very same case, are used by the defense to evaluate the severity of a claim.

Cases involving issues of medical malpractice, personal injury or workers’ compensation, for example, hinge upon the ability of a paralegal to extract the subjective, objective, assessment and plan information from the medical records. As noted below, while these facts are crucial to the litigation or evaluation of the case, it is equally important to scratch below the surface to uncover other significant information to support or defend the claim.

• Identity of family physician. When reviewing medical records, a paralegal should locate the name of the individual’s family physician. The records of the family physician constitute an important part of the damages in a case. The family physician records serve as a snapshot into the individual’s medical history and also contain information on present treatment as well as recommendations for future care. The records may also contain information not readily available in other provider records, such as laboratory results, changes in medication, messages and completed paperwork, as well as telephone calls by or to the individual. Additionally, the family physician records serve as a roadmap of treatment in cases where the individual may be an otherwise poor historian.

• Pharmacy ledger. A paralegal should also review medical records for any references to medications or pharmacies’ ledgers. These records will contain listings of daily medication regimens as well as the identity of health care providers who prescribe medication to the individual. The medication list or pharmacy ledger will provide an overview of the medications involved in the individual’s claim and indicate whether prescriptions were refilled timely.

• Statements that support the claim or defense. The medical records contain statements of an individual regarding his or her medical condition. These statements should be consistent in nature. Discuss any inconsistencies with your supervising attorney as these statements may affect a firm’s decision to accept representation of a client. Similarly, these inconsistent statements may also serve to bolster the defense of a claim. Thus, it is important for a paralegal to be aware of any potential issues.

• Diagnostic studies. The medical records will reference or contain copies of reports of diagnostic studies. A paralegal should review the medical documentation and prepare a separate listing of diagnostic studies in order to document all findings. The name of the referring provider, date and location of the study, as well as the finding, should be noted. Bear in mind that the study may have been completed by a practice group or provider other than the referring physician. The creation of this outline will also result in saving time at a later date, should the supervising attorney determine it is necessary to request copies of the original studies.

• Itemized billing statements. It is good practice to review the medical bills and cross reference each date of service with a corresponding medical bill. This step is a simple way to document all treatment by providers. This practice will also aid in identifying all health care providers and can also be a step-off point for creating a chronology of medical treatment. Following completion of this step, a paralegal should record the dates of any missing office notes or bills and clarify any issues with the client or supervising attorney. Following approval by the supervising attorney, a request should be issued to the respective provider in order to secure the missing records or bills.

• Identifying treatment by other providers. Individuals may not recall the names of all treating physicians. Medical records, however, reference treatment by other health care providers. A paralegal should review the medical records and identify all referenced physicians. In some instances, the records will reveal the identity of a physician unfamiliar in the case. Do not overlook the importance of this information. Instead, note the name of the physician and perform research to determine the office location and specialty of that individual. Then, discuss the need for a separate request for those records with your supervising attorney.

• Exacerbating or mitigating circumstances. Paralegals should review the medical records for any information regarding incidents other than the one giving rise to the claim. This is important in order to identify any other incidents and their effect upon the credibility or damage aspect of a claim.

• Employment. Medical records may contain discussions or notations with regard to the occupation of the individual, including type of employment, current status, length of employment and any restrictions. This information will assist the legal team in supporting or refuting wage loss or future earnings claims. The same is true in Social Security, disability and workers’ compensation cases.

• Scholastic. Medical records also may reference scholastic information with respect to an individual. The scholastic information may include the identity of a school, performance and requests for any accommodations, as well as involvement or inability to participate in extracurricular activities. Again, these references may buttress the ability of the attorney to demonstrate any claim of impairment or lack thereof.

• Overall course of treatment. A paralegal should glean medical records to identify the scope of treatment and identify any potential issues. These issues may include past history, gaps in treatment or failure to comply with physician recommendations. Of course, these issues may require additional research, including further clarification with the client and/or a request for supplemental documentation. Similarly, a paralegal should be aware of any referrals as well as recommendations for future medical care, including references to any potential surgeries or changes in course of treatment. This review of the medical records will provide the attorney with a clear picture of the overall condition of the individual, including past, present and recommended future treatment.

Of course, a paralegal should be aware of ongoing ethical obligations and all applicable HIPAA rules with respect to confidentiality in obtaining, reviewing and handling medical, employment and scholastic records. Medical providers, employers and institutions should not be contacted directly by a paralegal without first obtaining proper authorization and discussing the issue with the supervising attorney.

As set forth above, the records of an individual will provide both a chronological review as well as statements regarding injuries and restrictions and thus are vital to the litigation or defense of a claim. While the detailed review of these records by a paralegal may seem like a daunting task, it will surely serve as a key component to the success of the case.

Christine M. Flynn is a litigation paralegal with the personal injury firm of Haggerty, Goldberg, Schleifer & Kupersmith in Philadelphia. She has over 24 years’ experience in the field. Flynn is the past president of The Philadelphia Association of Paralegals and currently serves as board adviser and director of membership.