Focus on: Breaking down the medical record

by • January 1, 2008 • UncategorizedComments Off on Focus on: Breaking down the medical record2979

By Dorajane Apuna, BSN, MA, RN, CCM, CNLCP

In preparing for cases, the most important files for a personal injury, medical malpractice or product liability case are the medical records. Most life care planners and legal nurse consultants are paid for their expertise in knowing how to find what they need in those records.

Knowledge of what is in the medical records and having a systematic way of not only reviewing the medical records, but how to ferret out the information, is critical. Missing records and omitted information are critical, too.

When interviewing a client for the first time, the most important item that is needed is the “Release for Medical Information.” With the HIPPA confidentiality rules, this is needed to acquire documents to support your case.

Make a list during the initial conversation of whom the client has seen for treatment, where he obtained his medications, if he was seen in the emergency room, clinics or physician offices since his injuries.

Obtaining records
Remember, billing and medical records may not be maintained at the treating facility, but in another office or warehouse. A separate request for each is needed. It is important to obtain the pharmacy billing records (including the pharmacy coupon used) prior to and subsequent to the incident in question. If possible, have the potential client bring his records for the initial interview. They will contain a thumbnail sketch of the patient’s medical care prior to the incident in question, identify prescribing or healthcare providers as well as documenting medications. This will aid in supporting damages.

Many medical records, especially nursing documents, are multiple pages with dates and signatures only on one page. Some companies will staple the multiple pages in order. This is helpful for establishing dates, times and providers in a chronological order.

Often, treatment and medications records are double-sided with initials, signatures and comments on the opposite side. Be sure to request double sided copies, or if single sided copies, request they be stapled together. These records may contain crucial information in a case.

As in any case of medical negligence or malpractice, the medical records are extremely important in proving the facts showing negligence, breach, causation and damages. Obtain all of the nursing home, clinic, urgent care, emergency room, ambulance, visiting nurse, occupational therapy, speech therapy, physical therapy and respiratory therapy records and all doctor and hospital records.

Sometimes urgent care, ambulatory care clinics, emergency rooms, ambulances, nursing and various therapy services are outsourced to independent contractors. Establish with the hospital or institution what care is provided by any outsourced companies and where to address medical records requests to ensure you are ordering all of the available medical records. Even if all of the available medical records are not part of the alleged incident and hence are not subject to the medical review, they should still be obtained as reference material.

In determining what is pertinent to a specific case, you need a reference point of your client’s health status prior to the current injury. The records just prior to and after an alleged incident are especially important in providing documentation as to the person’s medical condition, the extent of the alleged injuries as well as an indication of any probable long-lasting complications that may now exist.

Types of records
For each incident, the types of records listed below should be sorted into categories and then “Bates” stamped. For the ease of your firm or review, they should be tabbed as follows:
• Admission summary: Here, find documentation of the date and time of admission, the admitting diagnosis, the admitting physician and other basic admission information such as the client’s status data, insurance information and emergency notifications.
• Discharge summary: Here you will find the post-discharge instructions for lab tests, physician appointments and medications prescribed as well as instructions for physical activity and other treatments. This is important for hospital liability of wrongful discharge cases, medical malpractice and “bad baby” cases.
• Admission history and physical: This is completed by the admitting physician, but sometimes deferred to a medical resident or physician assistant. There may also be a separate document, “physician’s admission history and physical,” in some healthcare facilities.
• Physicians’ progress notes: As the daily account of patient’s progress, often this section gives the rationale behind changes in treatment or medication, and documents physician visits. It contains summaries of the different physician viewpoints for medical treatments, an ongoing treatment record and any changes in status including summaries of labs, diagnostics or medications.
• Emergency room records: Here one will find the condition upon arrival, chief medical complaints and possibly emergency room doctor evaluation of any tests performed such as ultrasound, radiology and laboratory tests. Also, recommendations for referral, admission or discharge are obtained here. These records may not be a part of the hospital records if the emergency room is operated by an independent contractor.
• Ambulance and EMS records: These records may be maintained by either an independent EMS service, a municipal fire department or a hospital EMS service. In some situations, the records of emergency response personnel such as the police and rescue portions of the fire department will also apply and will be separate from other EMS records. A separate request for each entity will be required in order to obtain all records.
• Consultation reports (from other professionals): These documents are of the different evaluations, recommendations of treatments by physicians, and other healthcare providers asked to consult in reference to patient care.
• Physician’s orders: These contain the treatments and medications ordered by treating doctors, and the corresponding dates and times. These orders should be signed by the physician ordering them, even if a telephone order, phone or verbal order was given to a nurse.
• Operating room records and report (physician, nursing and anesthesia records): These records note the various procedures performed and list the surgeons, nurses and anesthesia personnel present during surgery. Also documented will be the patient’s condition before, during and after surgery. Some hospitals document post-operative care in the PAR (post anesthesia recovery) record.
• Laboratory reports: These contain results of tests performed in the laboratory, and include not only the blood and urine tests, but also cultures of tissue and microscopic exams of tissue.
• Diagnostic and imaging reports: These are records of X-rays, CT scans, MRIs, bone scans, angiographic procedures, KUBs, etc. They include the reports by the radiologist, when the record was read and when the test was reviewed.
• Graph sheets: These sheets detail the ongoing vital signs and other basic functions, such as urinary and intestinal elimination, while a patient is in the hospital. Some graph sheets also document dietary and fluid intake. Here, find out the answers to hydration, weight shifts and basic flow of hospital stay.
• Treatment sheets: These can be broken down into specialty such as respiratory treatments and assessments, occupational treatments, records of rehabilitation, wound care, hot and cold therapy, location of physical therapy, etc. Dietary records, such as consultations, caloric recommendation and TPN requirements are kept in this section. Speech therapy notes and recommendations should be kept here, also.
• Medication sheets: This section contains the documentation of medications given by the nursing staff. They serves as an inventory from the pharmacy of what was sent and given. If medications are skipped, omitted or not given on schedule, they will show up in this area. The PRN medications are given on an “as needed” basis and may be listed separately from regularly scheduled medications.
• Nurses’ notes and nursing progress notes: This is a chronological documentation of a patient’s condition, physician visits, treatments given and changes in condition, as well as patient responses. Though usually written in longhand, more and more notes are seen electronically.
• Nursing care plans: Each patient has a general plan of care, and the foundation is determined by the policy of the healthcare facility. Generally the nursing care plan covers all treatments, medications and therapies ordered for the patient. Goals are also stated for patient care. Official nursing diagnoses are more frequently being documented in this area of records.
• Interdisciplinary or multidisciplinary progress notes (not used in all facilities): These notes document, in order, the combined progress of therapeutic departments, as opposed to separate progress notes maintained by each department. Included will be notes made by more than one department, such as speech, physical and occupational therapies.
• Other sources: Has the client seen other providers such as physical therapy, occupational therapy, psychological treatments or a podiatrist? Have you checked dental records? If the patient has been involved in a code situation, there should be notes providing such information. Nurses are aware that there are supervisory notes and quality assurance forms filled out during codes, but generally these are not obtainable.

Starting the review process
In beginning the review it is important to understand that the medical records have an order about them. The physician’s orders are the very meat of the documents. When each order is reviewed, there should be a supportive document in the file. For instance, if the physician orders lab work, a test or treatments, there should be a corresponding document showing not only the test that was ordered, but the results of that test and comments about the results in the progress notes.

Be sure to look at the paid medicals to ensure that the patient was charged for the test or procedure. If something was ordered and not followed through on, or there is no mention of it in the records, you know it was either missing from the records or a nursing error.

It is also important to see if specialists have been asked to consult. Their records indicate that there were either suspected or identified problems, and a clarification of problems was needed. When looking at the paid medicals, set up a day-by-day chart. In it you will see what was ordered, what was given and what was charged for. A clear picture of the medical progress can be obtained, just following this simple system.

Reference books and web sites
If you are consistently reviewing medical records or summarizing, it is important to have a working knowledge of medical words and terminology. Medical records are the “gold mine” for the attorney, paralegal or LNC if he or she knows what to look for diagnostically. I suggest having the services of a critical-thinking legal nurse consultant for consults. 

The terms used in the medical records can be confusing and the rationale for diagnosis and treatment may not be clear. In other instances, you will wish to review a standard of care as it relates to your client’s diagnosis and treatment.

The list of references in print and on-line are in-depth references to assist you with both understanding and in having a general knowledge about a specific diagnoses.

Note: These references are on our web site at

Dorajane Apuna, BSN, MA, RN, CCM, CNLCP is a nurse consultant and life care planner based in Sacramento, Calif.;

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