Index of Medical Records: A Key to Success

You are an expert witness or a legal nurse consultant who sends medical records to an expert witness. An up-to-date index of medical records is a key to success. It helps both the expert and the attorneys quickly determine which records an expert has received.

How to create an index of medical records

• Avery produces colored tabs and an index page which, when used with their software, creates a neatly printed index. Avery produces tabs 1-5, 1-8, 1-10, and 1-15. It is ideal to use their indexes when you can anticipate how many sections of records you’ll have. However, it becomes cumbersome to supplement the index with new entries and tabs.
• An easier and simpler way to create an index is to use the small sets of white index tabs. They come in sets of 1-25, 26-50, 51-75 and 76-100. These tabs cost less than Avery tabs and are more versatile. You can create a simple index of medical records by typing on a plain piece of paper which identifies the documents found under each tab. It is easy to replace when you receive additional records.

The index is used to create a list of documents at the beginning of the expert report.

Question: “Why can’t an expert write a global statement in her expert report that she received materials?”

It is not sufficient to type, “I received office visits, radiology reports, depositions, reports and other medical care documents”.

Each item must be listed. Listing the documents you reviewed at the beginning of the report serves a few purposes. First, it shows the scope of what you received from the law firm. Second, it is useful when you are deposed because it answers the question, “What records and documents did you have at the time you wrote your report?” Your index of medical records will make creating this list easy.

Your list should be detailed and either numbered or bulleted. Include date ranges of admissions (for example, 3/15/15 – 3/19/15) and physician office visits (for example, 7/16/12 – 3/15/15).

Question: “Why do I need to list items that were not pertinent to the issue?”

Sometimes your focus is on what occurred in one part of the patient’s care but you receive medical records for care before or after that event. It is not appropriate to omit items that were not central to the care in question. These records may have been sent to you because the attorney wanted to give you “everything”. These records could be important. Sometimes there are comments in subsequent records that describe the care in question. For example, a fall in a nursing home may be described in an emergency department record.

You may be asked in testimony if you reviewed the subsequent records. You are not expected to read every page of records that do not have a bearing on the care under question, but you should list them in your report as materials you received. You might testify that you received them but your focus was on the care in question.

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