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When reviewing a case, it is important that it is organized well. When your case comes in, it’s either a box of random photocopied records from various facilities, or maybe it’s similar to a case we at Summit Medical Litigation Consulting recently received, where they were all on a disk, with 3,500 pages of records, including:

• Admissions, DNR, Advance Directives & Living Wills
• Transfers & Discharges from the various facilities
• History & Physicals
• ER Reports
• MD Progress Notes
• MD Orders
• MD Consults, including Podiatry, Dental, Optometry and others
• Nursing Assessments
• Nurses Notes
• Nurses Monthly Statements
• MDS
• RAP
• Care Plans
• Activities of Daily Living
• Bowel & Bladder documentation
• Restraints
• Vital Sign reports
• Intake & Output records
• MARS & Treatment records
• Pharmacy records
• Rehab notes
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Respiratory Therapy
• Social Services
• Activities
• Nutrition
• LABS, EKG, Xrays, Ultrasound & other tests
• Hospice reports

Needless to say, there are a lot of notes, from a lot of parts of the hospital or other facilities. In order for them to be properly reviewed, they must, must, must, be sorted through and organized in such a way that they can now be tabbed & indexed so that the nurse who is reviewing the case can do so efficiently. She will likely need to go back and forth, during certain times of the patient’s stay, to check for possible negligence or any other inconsistencies and negative indicators. With properly organized records, it also makes it possible for the nurse to see instances of non-compliance on the part of the patient, as well as interference and obstruction by the family. Also, it enables the attorneys, with relative ease, to go to the referenced section and retrieve the necessary evidence and data that will be helpful in winning the case.

If you do not intend to use a Legal Nurse Consultant to review your case, we recommend that you spend the necessary man-hours to get the documents organized well. Take the time to sort through all of the above areas and put them in an order and a sequence so that you don’t go out of your mind going through what seems to be redundant jibberish.

In the next article, we will go over other useful tips and tools that we hope will help you win your case.

Andra DeCarlo, RN

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