PI Brief Update

The Importance of The Medical Records Review - Dr Mark Burgin

15/01/26. Dr Mark Burgin discusses what medical experts mean by the words they use to describe their process of medical records review and how this impacts the legal case.

Summarising over 5000 medical records over 30 years as a GP, medical expert and disability analysis has been a large part of my work life. During that time improvements in technology have impacted the quality and detail that is possible. Now even handwritten records in another language can be faithfully transcribed into a form the court can read with ease.

The purpose of a medical records review varies from a few extracts to confirm the diagnosis to a full forensic records review to rule out alternative causes of death in a victim. The expert may perform the review themselves or have a summariser to do the work. The worrying use of unsafe AI practices to assist the expert create a summary has not been widely discussed.

In this article I will consider the various methodologies used in medical records review, the purposes that these reviews can be used for and safe use. Lawyers should instruct their experts to use an appropriate methodology for the case and in complex cases consider obtaining expert services. The time saved by having a single 20 page transcription of the medical records rather than 2000 pages cannot be understated. In a complex case up to 10 different professionals can separately try to read the medical records.

Pagination

Although medical records are usually provided as a single chronological PDF from each provider there is increasing use of pagination services. These companies will put the records in order, check that third party records have been removed and create an index. The added value of pagination services is difficult to assess as medical records are complex interconnected documents. It can be challenging to improve the presentation or ease of use.

Summary

The summary is often at the start of GP records or hospital letters and is useful to orient the reader. The two major limitations of the summary are that often the entry contains insufficient information to understand the diagnosis and omissions (e.g. symptoms) are common. An expert will normally double check the records for further information and expand the summary with dated entries of symptoms.

This more complete summary of the material entries allows the reader to have an overview of the medical records and identify important entries. Where the purpose of the review is to determine if the symptoms were pre-existing or new this is usually sufficient. For cases where for instance the person is disabled more information is required.

Extracts

Extracting the most important documents and providing them as an image or transcript avoids the problem of vague or unclear data. The reader can see the original document or an explanation and weigh up the evidence themselves. Most cases rely upon a few material entries and other entries have more of a supportive role. Many experts use a combination of the extracts, explanations and the summary.

One problem that lawyers should be aware of with extracts is that they usually focus on the post event records. This can mean that an important record perhaps years prior to the event is missed. As AI can be asked to read images as well as text it is becoming easier for lawyers to put the medical records into AI and find missing entries that challenge the opinions.

Case presentation

In clinical literature the case is presented as a story of a clinical episode. This is the most common review of a case online and the default approach taken by AI. Although it is highly accessible it suffers from significant limitations in a legal case. The presented information is selected by the author and inconsistent information may be omitted. The focus is on the event rather than the pre-existing problems and it contains opinions rather than facts.

Consultation analysis

Analysing a consultation for the four main components (assessment, data, red flags and patient involvement) is a specialised technique for clinical negligence. The expert takes a single consultation and considers whether there is evidence that the doctor took a logical approach. The analysis can help the court assess the quality of the consultation in a semi quantitative approach.

Transcription

Transcribing medical records involves identifying entries that contain medical information and copying them. The expert then removes all the administrative information particularly computer generated headings. The entry is then modified so that it makes sense. This process is like translation starting with correction of simple spelling mistakes and acronyms and punctuation usually being enough for the entry to make sense. In challenging cases a brief explanation is added.

The purpose of transcription is to extract all the available information from the medical records. OCR has made typed records easier to copy in its original form without having to retype the text. Images can be included for diagrams or graphs but an explanation is usually more effective for non medical professionals who may struggle to interpret the data. A transcription should be good enough to replace the need to read the medical records.

Transcribing medical records is more expensive but is not unrealistic in a suitable case. The time taken to transcribe medical records is similar with small and large volumes of records. The expert’s role is to obtain information so in a small record they may spend much of their time checking that aspects are missing. In a larger record there is usually summaries and good letters that lay out the issues clearly. Paradoxically it can be quicker to transcribe a larger record.

Transcribing is the gold standard for medical legal expert reports because it is complete, easy to read, can be read repeatedly, extracts can be copied and it identifies gaps. Having a single chronological text dramatically reduces the time taken for other professionals. Using a copy of the entry rather than trying to cross reference the medical records dramatically improves both clarification and cross examination.

Limits to evidence

It is rare for the medical expert to be provided with all the material records and often they are offered fragments. Many medical reports do not make clear the limits of the evidence and methodologies such as extracts can hide the limited available information. Including the date of printing of records and any limitations on the dates that were selected can also help the court understand how limited the medical evidence is.

I recommend having a series of headings in the report so that the court can easily identify the missing evidence. Also the expert should explain what that missing evidence would address. In complex cases this can ensure that the expert has communicated clearly how to narrow ranges of opinion. Often the key evidence will be found on a poorly copied handwritten record and be the last to be located.

Forensic medical records review

Forensic medical records review is a process of cross referencing all the available information with the medical records. Some of the techniques are used for instance in high value clinical negligence cases where the administrative records, the statements and the medical records are combined. The expert creates a timeline so that evidence from each source can be examined at each time point. This can help identify missing evidence and potential sources that can be explored.

Conclusion

As an expert in medical aspects I am able to provide opinions based upon the history, past medical history, social history, chronological progression, effects on everyday life, the examination and my experience. I can discuss the inconsistencies and indicate the likely explanations but without the medical evidence I am like a lawyer without the legal papers. It makes my job more difficult but not impossible, I need to ask more questions and it takes longer and the picture that I can create at the end has less clarity.

Medical records confirm the basis of medical diagnoses, contemporaneously record symptoms that might be misremembered by the person and use precise technical language. Occasionally people have their own very different versions of their medical problems which differ from those in their records. Often people will simply forget that they had previously seen a doctor for the same problem or feel that it is not worth mentioning.

Lawyers should be aware of the different methodologies used by experts and choose the most appropriate for the issues of the case. In contentious cases it is better to err on the side of caution and obtain a more thorough review. Having a transcription at the start of the case can ensure that all instructions and pleadings have a factual basis. The costs of experts may be dramatically reduced if for instance a specialist’s reading time is reduced from 20 hours to 2.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 01226 761937 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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