When performing a medical records review, if you’re looking for a list of injuries, as you commonly are in criminal law, you will look at the emergency department (ED or ER) reports and/or the ambulance reports.
Ambulance/Fire: The vast majority of the time, I have to request that the ambulance and/or fire records be subpoenaed. This is a great source of information! A lot can change from the scene to the ER and the paramedics will document that. And the best part is they have a very concise narrative that tells you exactly what they did and saw. Sometimes, I will catch facts in the paramedic’s report that isn’t documented anywhere else. Was the patient found face up (supine) or face down (prone)? A timeline of events is critical in a case involving a seizure. You have to remember that the paramedics are usually the first medical professionals to set eyes on the patient. Having to rely on the police officers and witnesses to tell me what the patient looked like at the scene is not ideal. Plus, the paramedic’s narrative is not usually overly technical and is written much like a story. This is a great place to start your review on any criminal case.
Emergency Department: Ideally, there will be a typed summary from the emergency room physician, but it is often hard to read because it’s mixed up with vital signs, orders (see the “note of caution” below) and procedures, or it simply doesn’t exist. ED staff tends to keep their documentation to a bare minimum. So, in ER reports look for the discharge diagnoses. Even if they are admitted to the hospital, there will be a discharge diagnosis because the ER is considered an outpatient service, so they are “discharged” from the ER and then admitted to the hospital. The discharge diagnosis is usually located on the bottom of the doctor’s notes – usually labeled “Doctor’s Progress Notes”, “History and Physical”, or sometimes “Emergency Physician Record”. Another good source for a list of injuries is the triage note from the ER. This note is written by the first nurse to see the patient, so it will be the first impression of how the patient arrived in the ER. This will not include any diagnoses that require procedures (like CT Scans), but it will include the patient’s mental status, their vital signs and the overall status.
This month we are discussing Medical Record Review. The blog topics for this month are:
- Medical Records: Where to start (5/5/16)
- Medical Records: Emergency Records (5/12/16)
- Medical Records: Complications and Procedures (5/19/16)
- Medical Records: Abbreviations (5/26/16)
Note: To see all posts in this topic, click here