Evaluating medical documentation and sifting through the jargon to get to what you need to know.
Medical records can be intimidating and tedious for any criminal attorney or investigator to
review. This session will be an overview of the medical record and what you need to focus on to help your clients. Key words and abbreviations will be discussed, as well as where you should look for the most comprehensive and understandable summary of the medical care provided.
To make it relevant and interesting, an actual case and its medical records will be included in the presentation. How injuries are evaluated in the hospital will also be covered.

Highlights / Agenda

Discharge Summary

  • Review of records that summarize the patient’s care while in the hospital
  • Distinguishing between narrative reports

Surgery and Radiology

  • How to read operative reports
  • Where to find the information you need on XRay and CT Scan reports

Emergency Department Reports

  • Review of the types of records and where to find critical information
  • Brief review of labs

Medications and Orders

  • When is a drug actually given and why orders can be confusing

Transport Records

  • How to tell the difference between Pre-hospital (911 providers) and Interfacility transports and levels of care provided
  • What information can be critical to your case

Objectives

Upon completion of the presentation, the attendee will:
1. Be able to recognize basic, frequently used medical abbreviations and interpret them.
2. Know where to look for a comprehensive, focused summary of the medical care provided.
3. Know where to look to determine injuries, injury severity, and treatment.
4. Recognize radiology and operative reports and know how to interpret them.
5. Determine what medications were given and when they were given.
6. Know when to enlist an expert’s help with medical record/injury interpretation.
7. Be familiar with how injuries are evaluated in the hospital.

“I attended the medical records training today and it was one the most helpful trainings I’ve been to in a long time. Easy to follow and a ton of very helpful information packed into a short amount of time. I signed up for the other 3 as soon as I was done. Thank you!! I bet I’ll be reaching out for help in the future. Thank you”

– Paul

“Great information. I especially appreciated the discussion about types of medical records that can be helpful and may be out there, including language to include in the request.”

– Sara