Step-by-step agenda

What a good medical records review system does

An advocate needs a client’s medical records to prove the fact the legal matter turns on. Here is what a good system does, in order, with a question for you at each step.

Several stages here can be handled by ordinary software that follows fixed rules, and only some call for an AI model. Keeping the two apart makes each one easier to test and easier to replace later, so each part below says which kind of technology the work calls for.

Answer the questions on the parts you know from your own practice. The Commons team reads every answer, fixes what the list gets wrong, and takes the harder questions to the cohort working on this area.

The rest of this workflow package is here, with how this works today, what a good system does, and the assets the cohort is drafting.

Part 1

Finding the sources

The advocate works out which providers, clinics, hospitals, and agencies hold the client’s records. Everything after this is checked against that list, and a provider nobody names is a provider nobody requests from. An AI model or a guided interview can do this work.

What a good system does

What it must never do

Which providers do your clients forget about?

Answer this

Part 2

Requesting the records and tracking them

The advocate sends signed releases and requests, follows up, and keeps a log of what has arrived. Knowing which requests are still outstanding, and when to follow up, is the whole job here. Fixed rules can do this work.

What a good system does

What does your request log have to show you?

Answer this

Part 3

Collecting and preparing what arrives

Records come by mail, fax, portal, agency download, and from the client. The advocate turns them into searchable files with page numbers, because every citation later depends on those numbers. Fixed rules can do this work.

What a good system does

What it must never do

What arrives in a form your tools cannot read?

Answer this

Part 4

Organizing the records

The advocate removes duplicates and sorts the records by provider and date. The same pages arrive from a provider and from an agency file, and somebody has to sort out which pages are new. Fixed rules find the exact duplicates, and a model is only needed for the near ones.

What a good system does

What it must never do

Where do the duplicate pages in your files come from?

Answer this

Part 5

Reading the records and pulling out what matters

The advocate reads the records, pulls out the findings, and builds an index or a chronology with page citations. A careful advocate builds that index while reading, logging page numbers by section and flagging findings, and then uses the index to navigate the record. This stage calls for an AI model.

What a good system does

What it must never do

What do you pull out of a record first?

Answer this

Part 6

Checking what is missing

The advocate compares what arrived against what should exist, including treatment gaps inside the records. Knowing that information is absent from a record is as much a finding as anything in it. Fixed rules do the comparison, and a model is needed for the gaps inside the records.

What a good system does

What it must never do

What is usually missing when the records arrive?

Answer this

Part 7

Applying the records to the legal question

The advocate connects the findings to the legal standard in the matter and may ask a treating provider for a statement. In a disability benefits case the fact is that the client cannot work. In a disability rights matter it may be the client’s need for an accommodation. In a medical legal partnership it may be the link between the client’s housing conditions and their health. This stage calls for an AI model, with the advocate reviewing what it produces.

What a good system does

What it must never do

Which fact does your case turn on, and where in the record is it?

Answer this

Part 8

Using the records and protecting them

The advocate cites the records in filings, letters, or negotiations, and keeps them stored and shared only as the client’s consent and the law allow. Medical records are protected health information, and an advocate needs to know how a tool stores, uses, and shares the data before putting a client’s file into it.

What a good system does

What it must never do

What does your program require before a client’s record goes into a tool?

Answer this

Part 9

Putting it in front of staff and clients

A tool that works still has to reach a program. The cost includes the time spent on permissions, user accounts, and preparing records before the tool can use them, and the program has to be able to tell a client that AI is being used.

What a good system does

What it must never do

What would your staff need to hear before this arrived in their week?

Answer this

Part 10

Knowing whether it works

Each stage has its own test, which is what keeping the fixed rules and the model apart buys. A test client’s history, with duplicates and missing providers planted in it, is enough to run most of them.

What a good system does

What would you need to see before you put a client’s record through this?

Answer this

What happens to what you write

Every note comes to the Commons team. We read it, correct what this list gets wrong, and publish a new version saying what changed. The questions that need practitioners to argue them out go to the cohort for this area, which writes the detailed specification from what comes back.

A note about one line is as useful as a note that adds a whole step. If what you know is how your program handles a client who opts out, write about that.

The two agendas for this workflow

You are reading this one

Step-by-step agenda

This is the first round, and it collects what the people who do this work say a tool has to do, in the order the work happens and in plain words. Read it to argue with it, to correct it, and to say what your jurisdiction needs.

Not written yet

Functional agenda

The cohort writes the detailed specification after this round, using the answers that come back from this page. It numbers every capability, states the standard each one has to meet, and sorts them by the scope of the system being built, so a builder can build against it and an evaluator can test against it.

The cohort drafts this one next