Organizing the Medical Record for Healthcare Expert Witness Review

In preparation for your healthcare expert witness's review of the case, at the outset, counsel should make sure that ALL the relevant medical records have been obtained and are ready for submission. These include, but are not limited to, emergency room records or admission chart, operative reports, progress notes, nurses' notes, physicians' orders, lab reports, x-rays and other films, consultants' reports, social worker notes, discharge summaries, autopsy reports, and death certificates. The medical expert will base his/her opinions solely on the information submitted.


Counsel should facilitate expert review by making a lay determination of some key pieces of information that the expert can review before beginning his/her review of the case. For example, counsel should determine why the care in question was desired, what care was actually rendered, the timeliness of that care, the appropriateness of that care (to the extent a lay review will permit), and the cause of the problematic result that brought the matter to question in the first place. Then, the information should be briefly summarized by episode or provider for the reviewer. This enhances review efficiency and often avoids delays associated with medical expert reviewer questions regarding timeframe/sequencing. Record organization will contribute to a more efficient medical review. Numbering pages, indexing sections, highlighting key facts and results may sound excessive or unnecessary to some, but can greatly help the reviewer make the best use of his/her time.


Do not rely on the medical expert to ferret out the important medical-legal aspects of the case. To do so will, at best, result in a less efficient review and, at worst, lead to errors and oversights that can impair the evaluation. Also, most experts prefer hard copies of the records rather than on disc or on-line. It is easier for the expert to scan and page through a paper chart. This contributes to a thorough and timely review, and would also save counsel money because of reduced record review time.

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