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Medical Records Review in Personal Injury - Dr Mark Burgin

26/04/19. Dr. Mark Burgin BM BCh (oxon) MRCGP explains why MedCo should consider providing guidance on medical records review to experts and solicitors.

The complex and time-consuming nature of an expert medical records review combined with a trivial payment for that review has led to a nihilist approach.

Since GDPR obtaining medical records is always proportionate on price alone but unless there is a question that needs answering it is not necessary.

A & E records typically contain more of the material details than a GP record as they include all areas of injury, descriptions of the visible injuries and diagnoses.

The absence of evidence is not evidence of absence meaning the GP expert has to transcribe the records and then provide an interpretation of those records to see what is missing.

There is a small minority of cases where the expert is instructed to answer part 35 questions without reference to the medical records which can mislead the court.

When medical records review is necessary

When the findings on examination indicate pre-existing problems but the claimant denies any history review can provide evidence to resolve the inconsistency.

When the claimant is returning for a re-examination the records can assist in supporting or contradicting the claimant’s ongoing symptoms.

In LVI cases the medical records can confirm pre-existing injuries that make the claimant unusually susceptible to a small impact.

Where questions have been raised on the expert opinions the medical records can provide further information to support the claimant’s or the defendant’s opinions.

Where the injuries were extensive or non-soft tissue (e.g. fracture) the medical records can provide confirmation of the exact diagnosis of injury (such as whether a joint was involved).

Where a specialist expert report is required the generalist expert can provide a detailed assessment of the records to save specialist time and provide interpretation of ambiguous records.

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