REVIEW:

Review of medical records

Dr. Zünkeler performs independent reviews of medical records, diagnostic imaging studies, and other documentation for insurance companies and legal professionals on behalf of both plaintiffs and defendants. It is important that Dr. Zünkeler be provided with the imaging studies themselves on CD (whenever possible), not just the radiology reports. Depending on the situation, an in-depth review of the records and diagnostic imaging studies of an examinee with a complex brain or spine issue may allow insights into causation, conformance with the standard of care, and neurosurgical case and complication management.

A careful review of a complete set of medical records and relevant imaging studies can provide an experienced reviewer with valid insights. A written report based on a record review may be able to address the following issues:

  • appropriateness of medical/surgical care,
  • pre-existing and subsequent medical conditions,
  • causal relationship of medical/surgical care, and
  • future treatment needs and costs, including diagnostic testing and follow-up visits.

Even the most careful review of available medical records and diagnostic imaging studies is limited because of its reliance on the documentation of other providers and on the medical records and studies provided for review (i.e. other records and studies may exist that have not been provided).

A record review can help to establish a basis on which to form valid opinions, but there are two main caveats:

  • the reviewer does not physically examine the patient, and
  • the reviewer cannot obtain a verbal history.

In some instances, it may be possible and helpful to schedule an IME after a record review has been completed.

The time frame for a record review varies depending on the record volume and case complexity. In most cases, we request a minimum of a 1-month lead time upon receipt of the medical records and imaging studies to conduct the review and create a typed report.