Can medical and legal documentation be easy?


Medical and legal documentation can be an insurmountable challenge to the uninitiated. There is no “Easy Button”. But, you can streamline the process and still be certain to cover all the relevant Decision Points in your documentation.

Here are 3 ways you can make your documentation better:

1. Understand the process
We are constantly on the lookout for the most up to date information and most knowledgeable legal and medical experts related to the field of motor vehicle injury. Let’s face it trying to figure this stuff out for yourself is near impossible. Did you know insurance companies purposefully keep their evaluation processes a secret? Did you also know they refuse to offer any insight into their claims evaluation process even though they have been court ordered to do so (see Allstate)

2. Use Software to help you document
We use electronic record keeping to track the daily visits of care in our office. This allows us to present a complete and comprehensive documentation related to the injuries our patients sustain. We go a step further and use proven narrative and case documenting software called

Liberator software and MedicFusion. In an effort to remain as paperless as possible we also perform digital X-Rays in our office with a Fuji Digital X-ray unit. By leveraging computer software technology we are able to decrease the time it takes to process all of the required documentation for injured patients.

3. Work with like-minded professionals
You understand the details related to documenting injured patients or clients, but do the peers you work with fully understand this process? Making sure to include the proper decision points in your documentation is crucial. However, if the legal and medical documentation does not agree then the insurance adjuster may ignore the decision points and fail to put them into the claim evaluation software. If you decide to work with our office you can be certain we will make every effort to document properly.

Medical legal documentation evolves as state laws change and over time insurance policies change. With the use of up to date software and current standards of practice you stand the best chance of properly documenting your clients or patients case.

Sometimes it is necessary to have someone look over your injury documentation to be certain you have not missed any essential details. Sometimes he insurance company is refusing a fair settlement based on the current documentation. Either way, if you are having trouble with your injury case or have questions related to your paperwork you can contact the author of this article directly.

Dr. Tim Redenbaugh has been practicing since 1998 and invested hundreds of hours into injury related treatment and documentation related education. He has the expertise to evaluate your medical documentation to determine if all the required information is presented properly and thoroughly. If you would like his help, please reach out to him here or call his office direct at (712)732-3349.


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