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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...