I can remember when I first started reviewing medical records. They don’t teach that skill in law school and it felt more like looking for needles in a haystack, turning the pages, and trying to decipher the different handwriting, acronyms, and shorthand. Some mysteries never get solved and some were solved with the help of FBI forensic tactics parsing through the paper and ink.
Like anything, a medical record review is something you learn over time. To get really good at it, you need exposure to all manner and types of cases that force you deep down in every part of the chart. Reading lab results is different from reading nursing notes which are different from the radiology reports. It takes years of this kind of exposure to develop the necessary skill.
In legal terms, discovery is “the compulsory disclosure, by a party to an action, of relevant documents referred to by the other party.” But receiving a disclosure is different from knowing and understanding it. Discovering what is in your discovery is an acquired skill.
Here is a link to a case we litigated to the Supreme Court of Florida that solidified patient rights to evidence of medical errors from Hospitals.
