Medical Record Review for PI Firms: Where the Time Goes

Medical records drive damages in a personal injury case, and reviewing them is usually the longest step between signing a client and sending a demand. This post covers what the review has to capture, where the hours go, and what changes when the first pass is done by software that cites its sources.

What a PI record review has to capture

• Every treating provider and facility, including referrals the client forgot to mention.
• Dates of service in order, from the ER visit to the last appointment.
• Complaints, findings, diagnoses and procedures at each visit.
• Imaging and what it showed.
• Gaps in treatment and the reason, if the record gives one.
• Prior complaints or treatment for the same body part.
• Statements tying the symptoms to the incident, and any that cut the other way.
• Bills matched to the visits they cover.

Where the hours go

The reading itself is only part of it. Time also goes to:

• finding the same visit in three different productions and working out which copy is complete;
• records that arrive out of order, scanned sideways, or without dates on every page;
• searching for one fact, such as who first recommended surgery, across a few thousand pages;
• retyping dates and providers into a chronology table;
• re-checking the chronology when new records arrive.

When this work backs up, the demand waits, and so does the attorney's read on the case.

What a cited AI first pass changes

In LawUnleashed, a team uploads the records to a project and runs a chronology or summary from a template. Each entry carries a citation to the document and page it came from. The reviewer reads the chronology with the source open beside it and the cited text highlighted, then fixes or removes entries that are wrong.

The same file can be searched with plain questions, such as "when did the client first report neck pain?", and the answer points to the pages. Review questions about prior conditions, treatment gaps and inconsistent histories can be saved as a firm prompt and run on every file.

The paralegal's job moves from typing the chronology to checking it. That check still has to happen on every entry, because OCR and AI both make mistakes on handwritten notes and poor scans.

Keeping the review defensible

• Check each chronology entry against the cited page before it goes into a demand.
• Mark entries the reviewer confirmed versus ones still unchecked.
• Keep the firm's chronology format in a template so every file looks the same.
• Follow your firm's AI policy and your state bar's guidance; ABA Formal Opinion 512 (July 29, 2024) covers competence, confidentiality and supervision when using AI tools.

Handling medical records

Records contain protected health information. LawUnleashed states that it can operate as a HIPAA business associate for applicable customers, with vendor BAAs, documented procedures, workforce training, access controls, audit logging, backups and encrypted infrastructure. Ask for a BAA if your firm needs one.

Start a free trial with one user and projects of up to 1,000 pages, no credit card.

Sources

• LawUnleashed workflow and security: https://www.lawunleashed.ai/
• ABA Formal Opinion 512, Generative Artificial Intelligence Tools (July 29, 2024): https://www.americanbar.org/content/dam/aba/administrative/professional_responsibility/ethics-opinions/aba-formal-opinion-512.pdf

Related: AI prompts and templates for PI teams.