For more information on the hospital course, other documents to look for include: Operative reports: These are generated if the patient undergoes any surgeries, and a separate report will be generated for each operation. Look…
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…
If you’re looking for the “story” of how the patient entered the hospital and what happened while he/she was there, go to the Discharge Summary (Caution: This is different than the Discharge Instructions, which are…
On the day prior to his arrest, Mr. Smith went to see a psychiatrist and was placed on Wellbutrin. The doctor claimed to have considered the interactions of his medications and the hepatotoxic potential, yet…
Studies from 2010 indicate that “Patients with impaired renal or hepatic function may have difficulty clearing or metabolizing opioids and concurrent medications, leading to increased risk of adverse events.” At the time of his arrest,…
The liver is a large organ that is located on the upper right side of the body. It is considered part of the digestive system as it detoxifies the products we ingest, including medications, and…
Mr. Smith had a significant and lengthy medical history that included Hepatitis C, Cirrhosis, ITP, Diabetes, vertigo, peptic ulcer disease, depression, IV Drug abuse (heroin and cocaine), and prescription narcotic addiction. Mr. Smith’s history of…
We have reviewed medical records from clients with burn injuries that have more than twenty diagnoses documented. This is because of the numerous complications associated with severe burns. The skin is the largest organ of…
The client with severe burns will be hospitalized for weeks or months. Burn wounds often require painful dressing changes, surgery and grafting. Preservation of function and prevention of complications are the priorities of care. A…
It is important to obtain and review medical records from the ambulance crew and emergency department in burn cases. The first responders will obtain information about the details of the fire, injuries and medical history.…
Mr. John Smith, age 40 sustained multiple injuries when he jumped from the second story of a burning house. He was treated at the scene by emergency medical services and transported to the emergency department…
Directionality and blade width may also be determined in a penetrating knife wound. If a hilt mark is present then directionality can be determined easily, but not all penetrating knife wounds have a hilt mark. …
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