A Comprehensive, Chronological Medical Summary Format

By Law Vendors staff

The objective of a medical summary is to tell the story that lies within a patient's medical records. That requires creating a concise, well-written narrative.

Unfortunately, too many medical summaries consist of a separate summary for each set of records. While it may seem natural to work this way, dividing the summary into multiple documents isolates each set of records from the broader context of the case’s full medical story.

What is needed is a single document - a comprehensive, chronological summary of all the records. But how do you do that when you're summarizing records one set at a time, with records that may come in weeks or months apart? And how do you keep it clear which entry came from which set of records?

Here is a summary format that solves those problems. It allows you to construct a complete chronological summary of all bills and records, build a list of all persons who have provided treatment, add records to the summary as they come in, and keep track of the origin of each individual entry - all in one document. 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.

Click here to see an example summary.

Section 1 - Bills
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 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. This list is going to provide you with a key to keeping track of where you found each entry in your summary, allowing you later to find an individual page in the mass of records.



Section 4 - The Summary
Here's where you create a complete chronological summary, weaving together records from different providers. You'll need four columns:

Date - the date of treatment.

Source - identifies where in the records you found this information. For example: "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 - identifies the individual who performed this treatment or recorded this note, 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 records come in, simply identify the date of treatment for a new entry, find that date in your summary, then insert the new record into chronological order.

In the example, when the records from Joe Smith came in I added Joe Smith, M.D. to my list of records. His was the third set that arrived at my office, so these become No. 3 in my list. On page 9 of Smith’s records is a report on surgery performed on May 24, 2007. I located where, chronologically, in the summary this entry should go. There is an entry dated 5/23/07, so the 5/24/07 surgery goes after that. Type in a couple of returns from the end of the 5/23/07 entry and start summarizing. Put the date in Column 1. Tab to Column 2 and note where in the records this information can be found: 3-9, the third set of records, page 9. Tab to Column 3 and type in the name of the doctor performing the surgery. Tab again and briefly summarize the doctor’s report.

This format makes it 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.