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…
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…
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