Traumatic Brain Injury or Mental Illness?

TBI and Mental Illness What if a defendant commits a crime because of being affected by either an acute brain injury or an acquired or inherited brain disease? This is called the “brain defense.” In criminal cases, defense attorneys are increasingly using clinical evidence of brain injury to either establish their client’s innocence or mitigate Read More...

Medical Records Review: Abbreviations

The last thing I want to cover is abbreviations. Reading a doctor’s handwriting alone is hard enough, and it is so much harder if it’s filled with unknown abbreviations. It is literally impossible to understand the medical records without knowing at least a few of the common abbreviations. For your benefit, I’ve created a list Read More...

Medical Records: Complications & Procedures

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 at the pre and post-procedure diagnosis. Radiological reports: Look at the “Impressions.” Again, there will be one report for each Read More...

Medical Records Review: Emergency Dept.

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. Read More...

Medical Records: Where to Start

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 essentially worthless unless you practice med-mal). The Discharge Summary is a synopsis of the major events in the time that Read More...