As a Professional Legal Nurse Consultant, you just got your first pile of medical records in a nursing malpractice lawsuit. You have been asked to organize them. Where do you start?
Organized medical records impact so many aspects of a case. First, as a PLNC, you will rely on the medical records and knowing where to find key documents is essential. Next, attorneys and the legal staff rely on them both in pretrial and trial proceedings.
Follow this Professional Legal Nurse Consultant roadmap to medical record organizational success:
- Clarify the instructions: Have you been asked to “Bates” stamp them – a paginated identifying numbering system. Have been asked to put them in a certain order – chronological or reverse chronological order. When does the attorney want the organized medical records back – once you get the deadline, consider how to return the medical records to the attorney.
- Compile the documents by sections: Proceed to put all medical records pertaining to a specific department, or event, into one stack, usually in chronological order. Continue to do this with the entire medical record.
- Gather all sections into one bundle: Put the multiple stacks into one complete pile beginning with what you would think would logically be the first section and proceeding to completion. You might want to follow the lead of how your hospital or employer organizes their medical record. In absence of a clear method, put them in the most local sequence.
- Bates stamp each page beginning in the bottom right corner: If the right corner is taken, or would require obscuring items in that corner, opt for the bottom left corner. If the left corner is taken, next look to the top right. If the top right in occupied, use the top left. Remember to Bates stamp each page in the same location, if possible.
The medical records are now ready to be placed into a binder. Punch the holes for binder insertion either along the left-hand side in a three-ring approach or at the top using a two-ring approach. Usually the law firm will provide the binders, but these can easily be purchased from an office supply company and reimbursement can then be sought.
If an index is requested, insert this before the medical records. Be sure to list each section by name and Bates stamp number where that particular section begins. An organized medical record is essential to a thorough review. Now, you are ready to move on to the next Professional Legal Nurse Consultant assignment.
