Did I Miss This Day in Medical School?

17 June 2012 / Chart Reviews / Comments Off on Did I Miss This Day in Medical School?

Did I miss this day in medical school? Very little is formally written about the process of chart review.

I can't recall any formal teaching, critique, or mentoring either in medical school or residency with reference to chart review skill. Chart review is a critical part of the medical legal report, yet probably the most underdeveloped talent in doctors. Style varies greatly between medical providers. Very little, if anything is written describing this important event in the medical legal report.

The question then really becomes, "What purpose does in medical chart review really serve, and who does it serve?”

Remember, these findings will serve as the third foundation for the report, following only the history and the physical exam/imaging. A well-written chart review will be informative and brief. This is an opportunity to set your report apart from all others that have come before.

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