A Step-by-Step Guide to Reviewing Electronic Health Records (EHR) for Attorneys

Did you know that up to 96% of hospitals in the United States had implemented an electronic health record system by 2019? This staggering and unrealistic adoption rate shows just how important EHRs are in modern healthcare and, by extension, in litigation involving medical issues. 

For attorneys who handle personal injury, medical malpractice, or insurance disputes, knowing how to review electronic health records is critical. But let’s be honest, diving into thousands of pages of digital notes, lab results, and imaging reports can be overwhelming. 

In this medical records analysis guide, we’ll walk through a clear, conversational roadmap that any lawyer can follow to ensure a thorough and accurate EHR review for attorneys, without needing a medical degree.

Also Read: Analyzing Medical Negligence: How Attorneys Use Medical Records Review.

Understanding EHR Systems

Most practices use popular platforms such as Epic, Cerner, Allscripts, or MEDITECH. While each system has unique labels, they share two main data types:

• Structured data: Dropdown menus, coded diagnoses (ICD-10), procedure codes (CPT), and lab values. You can sort and filter these easily, think of a spreadsheet where you can query “all chest X-rays between January and March 2020.”
• Unstructured data: Free-text notes written by physicians, nurses, or specialists. These include progress notes, operative reports, consultation summaries, and discharge instructions. This is commonly called unstructured health data.

Don’t gloss over unstructured notes. They often reveal subtle details like a doctor’s concern or a patient’s exact description of symptoms. When doing an EHR review for attorneys, you need both structured and unstructured data to build a complete picture.

Step-by-Step Review Process

Let’s get into the step-by-step medical records analysis guide tailored for legal professionals.

1. Initial Case Assessment

Before opening a single medical document, understand the case's scope. Ask:

• What is the alleged injury?
• What are the dates of importance?
• Who are the care providers involved?

This pre-review sets a clear focus and prevents time-wasting.

2. Identifying Relevant Records

You don’t need every record. Filter by:

• Timeframe (admission to discharge)
• Departments (emergency, surgery, etc.)
• Specific providers or procedures

Bonus Tip: Use an index or record inventory, if provided, to navigate large files efficiently.

3. Spotting Red Flags

This is where legal review of patient records becomes critical.

Look out for:

• Gaps in treatment: Unexplained absences in care.
• Duplications: Repeated notes or copy-paste documentation.
• Inconsistencies: Different versions of the same event.

These issues can indicate medical errors or even cover-ups.

4. Creating a Timeline of Medical Events

Chronologies are legal gold. Lay out:

• Date
• Event or procedure
• Provider involved
• Notes or outcomes

A clear timeline helps the jury (and you) understand the sequence of care.

At MedicalRecordsReview.com, professionals assist attorneys with building medical chronologies that are legally sound and medically accurate, reducing error and saving time.

Tools and Technologies

1. Legal Software for EHR Review

Many law firms now use specialized platforms to streamline how to review electronic health records:

• Concordance: A document management system that lets you tag, sort, and annotate records.
• Relativity: Often used for eDiscovery, but also supports medical record indexing and searching.
• CaseFleet: Built for chronologies and linking evidence to facts, ideal for personal injury and medical malpractice cases.

These tools let you attach notes, highlight text, and extract key metadata like author, date, and time. They can also generate reports summarizing findings.

2. OCR and Document Organization Tools

If you receive paper or scanned documents without text-search capability, OCR is a must. Popular OCR tools include Adobe Acrobat Pro and ABBYY FineReader. They convert images of text into searchable PDFs. Then, upload those to your legal document management system.

Folder Structure Tips:

By Facility: Hospital A, Clinic B, Imaging Center C.

By Date Range: 2020 Q1, 2020 Q2, etc.

By Provider Type: Physician notes, Nursing notes, Imaging.

By keeping a logical hierarchy, you minimize the chance of overlooking essential files.

Common Legal Challenges

Hidden Metadata and Access Logs

EHRs often contain metadata, timestamps showing who accessed or modified a record. This can be gold in a malpractice case: Did the surgeon finalize the operative note only after the lawsuit was filed? Metadata may reveal whether records were altered post-incident.

Redactions

Sometimes, defense counsel or hospitals redact sensitive information (e.g., HIV status, mental health history). While privacy is vital, excessive redactions can hamper your ability to construct a complete picture. If you suspect relevant data is missing, file a motion to compel unredacted records or a protective order to handle sensitive data carefully.

Mismatched Identifiers

Patient name typos, MRN (medical record number) inconsistencies, or mismatched dates of birth can lead to the wrong files. Always confirm basic identifiers on each document.

When to Involve Medical Experts?

Even with a detailed medical records analysis guide, attorneys can struggle to interpret technical data:

• Complex Lab Results: Interpreting platelet counts, D-dimer levels, or hormone panels often requires a clinician’s input.
• Imaging Reports: Radiology language can be dense. A radiologist can clarify the clinical significance of findings (e.g., “small ground-glass opacity”).
• Causation Opinions: In many malpractice cases, you need an expert to state whether a delayed diagnosis caused harm.

Benefits of Outsourcing Complex EHR Reviews

• Accuracy: Medical reviewers catch subtle errors that lawyers may miss.
• Efficiency: A medical expert can summarize thousands of pages faster than you can.
• Credibility: When you testify or present reports, having a clinician-backed analysis carries weight with judges and juries.

If billing rates are a concern, consider limited-scope reviews, in which the expert focuses on the most critical sections you flag.

Conclusion 

Mastering how to review electronic health records is essential for any litigator facing medical issues. You need to handle both structured and unstructured health data, spot gaps in EHR, build a solid timeline of medical events, and be aware of metadata or redaction pitfalls. Utilize OCR tools and legal software like Concordance or Relativity for efficient organization. 

Finally, know when to call in medical experts for technical interpretation or causation opinions. Attorneys who follow this practical, step-by-step approach can ensure their legal review of patient records is accurate, thorough, and ultimately persuasive. For templates and professional support, visit Medical Records Review, where expert guidance meets practical solutions (used once here).

Frequently Asked Questions (FAQs)

1.What are Electronic Health Records (EHRs), and why are they important in legal cases?

EHRs are digital records of a patient’s medical history. They are vital in legal cases as they help show what care was provided, when, and by whom.

2. How can attorneys identify key information in large EHR documents?

Start with relevant timeframes, focus on provider notes, and use legal software tools to highlight crucial facts.

3. What common mistakes should lawyers avoid when reviewing EHRs?

Don’t ignore unstructured data, skip creating a timeline, or assume all data is accurate without checking for errors or gaps.

4.How can attorneys spot missing or incomplete data in medical records?

Look for gaps in EHR, unexplained delays, skipped follow-ups, or overlapping notes. Cross-check with billing records and access logs.

5.When should a lawyer seek help from a medical expert during EHR review?

If the case is complex, involves multiple specialties, or when you're unsure about clinical meanings or standards of care.

6.What tools or software can help attorneys organize and analyze EHRs?

CaseMap, Adobe Acrobat Pro, and medical chronology tools like MedChron are helpful for organizing and analyzing records efficiently.

7.How can attorneys ensure that EHRs are authentic and unaltered?

Request audit logs, review access histories, and check for metadata discrepancies that could indicate tampering.