A Comprehensive, Chronological Medical Summary Form

By Law Vendors staff | September 1, 2009

What is the goal of a medical summary? Is it to regurgitate the high points of the records, to simply re-type whole passages? Absolutely not.

The objective is to tell the story that lies within the records. That requires creating a concise, well-written narrative.

Telling a case's medical story is a lot tougher to do when your summary consists of separate summaries for each separate set of records, because those entries lose the context that is found in a comprehensive, chronological summary. But how do you do that when you are summarizing records one set at a time? And how do you keep it clear which entry came from which page of records?

Here is a summary form that solves those problems. It allows you to construct a complete chronological summary of all records that puts each set of records in context with other sets, allowing you to add records to the summary as they come in while keeping track of the origin of each individual summary entry.

Click here to see the full example summary.

This format allows to you keep a summary of all medical bills, a list of all persons who have provided treatment, and the chronological record summary. Every attorney I've ever worked with likes this layout. I've used it for years and have found it extremely flexible and easy to use, even in cases with hundreds or thousands of pages of records.

Section 1 - Bills

After the style of the case, the first section is for medical bills. Under each provider, list the date of service, a very brief description of services provided (if shown in the bills), the total billed, and the total after any adjustments (insurance reductions or write-offs). For bills that show only charges and no payments or adjustments, leave the fourth column blank. I put the bill entries in a smaller point size, in this case twelve-point for the name of the provider and nine-point for the bill entries. Put an extra return between providers, and the grand total at the bottom.

Section 2 - Physicians

As you go through the records, list the name of each person who provided any treatment, from paramedics to ER doctors and nurses to primary physicians and physician assistants to surgeons to therapists. In parenthesis is the name of the facility where they work. This list will also come in handy for supplementing disclosure responses.

Section 3 - Records

List each set of records you summarize and assign a number to each set. If you get multiple sets from the same provider, give each set its own number. I simply number them in the order I summarize them.

Section 4 - Summary

Here's where you can create a complete chronological summary, weaving together records from different providers. You'll need four columns:

Date - the date of treatment.

Source - where in the records you found this information, for exampled: "4-33." In this example, "4" refers to the number assigned to this set in the list of records, Southwest Therapy. "33" refers to the page number in Southwest Therapy's records where this was found. This way, months after you wrote the summary, you can go find a specific page. In cases where there are no page numbers, the entry would simply be the number of the set of records.

Physician - whoever signed this record, whether it was a doctor, nurse, paramedic, tech, or whatever.

Description - paraphrase the information from the records. I like to start each entry with one or two words, like "Surgery" or "PT" or "Follow-up." This column is formatted with a hanging return that will automatically keep all of your description in this column.

As new sets of records come in, simply insert new records in chronological order, giving you a complete narrative of the patient's treatment rather than separate documents on each facility. It's even easy to summarize medical treatment from before the date of injury, resulting in not just a history of the treatment for the injury in question, but a more complete medical history.

Click here for a template in Microsoft Word. Feel free to save it to use and modify it as you see fit. All the tabs and returns are already set.