Our Services: Medical records

Add a Little SALT to your Cases

The services of a legal nurse consulting firm add a new dimension of flavoring to claims involving medical issues. The challenges of law warrant the use of experienced medical assistance in handling claims.

S: Screening

Screening medical malpractice cases for merit is more important now than ever before. The commitment of time and resources to these types of cases requires meticulous screening for liability, damages, and causation before cases are filed. Med League Support Services, Inc. provides screening of medical malpractice cases prior to filing a claim. Relevant medical literature that defines the standard of care helps to establish or refute the liability and causation. Evaluation of the permanency of damages is needed to pinpoint the injuries. Our services help to reduce the risks associated with pursuing these complex medical malpractice claims.  

A: Analyzing

Complex medical issues require a good grasp of the details found in medical records. The first step in analysis of medical records is careful organization of records. Pre-printed medical chart organizers used by Med League expedite the location of information in the record by experts and attorneys alike. We consistently receive compliments on how easy it is to use medical records that we have organized. Detailed medical summaries save the attorney time in finding the key information about symptoms, diagnoses, and treatment following a personal injury. Information about pre-existing conditions can dramatically influence the liability and damages of a claim. The details of a prior car accident, for example, may be revealed in medical records but never shared with the plaintiff’s attorney. Timelines can be developed to show a minute by minute account of key events, such as sudden changes in a patient’s condition in an operating room, or convey the details of a course of treatment over months of time. Med League is skilled in preparing demonstrative evidence which helps the jury understand the correlation between key events and the condition of the plaintiff. Such exhibits are useful for both asserting and refuting the plaintiff’s claims and can be presented in poster size, PowerPoint presentations or trial presentation software systems.   

L: Locating

It often takes a medical mind to locate key documents and pieces of information. A legal nurse consultant’s understanding of medical terminology and procedures guides the search in the most efficient manner. The attorney who thinks that medical records are complete may be surprised to learn that the medication administration records were not supplied by the hospital. Med League’s staff readily recognizes the omission. By understanding the documents that should be present, we quickly see what has not been supplied. One sentence in a report or a single laboratory value, such as a blood alcohol level, may be crucial in a claim. In one case, both the plaintiff attorney and claims adjuster believed that the driver was impaired at the time of the accident. Both missed the fact that Morphine was administered in the emergency department before the blood was tested for narcotics. The assertion that the driver was impaired was dropped after we pointed out the timing of the Morphine administration.     

Understanding the authoritative texts, internet resources, and professional healthcare associations is invaluable when it comes to locating key medical information. This assistance is essential when attempting to refute or substantiate a claim involving injuries from alleged defective products. Establishing causation can hinge on being able to locate the medical literature relevant to the case. Can mold in building cause birth defects? Can an abdominal injury cause a new onset of diabetes? Was it standard of care to do pulse oximetry readings on medical surgical units in 1995? Can trauma precipitate multiple sclerosis? Our staff has been asked to locate information to answer these kinds of questions. We are skilled in the process of hunting for the answers.

T: Transcribing/Translating

We are skilled in transcribing pages of medical records, from the single sheet emergency room record to 25 pages of a psychiatrist’s scribble. The world of medicine is filled with arcane medical terms and abbreviations. Attorneys can be stumped trying to read a medical report that is perfectly clear to a person with medical training. Understanding common prefixes and suffixes is useful in deciphering medical terms, as is a good medical dictionary. But comprehending medical terminology goes beyond the translation of the term into simpler language. Determining the significance of the medical information is made easier with the help of the medical knowledge base of a legal nurse consultant.

Abbreviations are useful timesavers when healthcare professionals are attempting to convey long terms in a minimum of time. For example, it is so much faster to write “CHTN with PIH” than it is to write “chronic hypertension with pregnancy induced hypertension.” However, this example makes the point that abbreviations can be confusing and having multiple meanings. For instance, the correct meaning of CVA (cerebral vascular accident or costovertebral angle) has to be deciphered in the context of other documentation surrounding the entry. There are large numbers of medical abbreviations that have more than one meaning. Knowing which abbreviation makes sense in the context of the note is learned through our years of exposure to medical records.

Healthcare facilities are encouraged to create and enforce the use of a standard list of abbreviations and to avoid using dangerous abbreviations. This is easier said than done. New abbreviations may enter a facility with a group of interns or residents who have picked up or created their own abbreviations at other facilities. Attending physicians may make up their own abbreviations known only to them. For example, one internist described his patients as “KGH” for “keeping good health.” In an effort to reduce medical errors caused by misinterpretation of abbreviations, the Joint Commission is encouraging facilities to post lists of unapproved abbreviations. Med League has compiled some of the most common medical abbreviations in our publication, The ABCs of Medical Abbreviations.

Using the SALT services of Med League helps to prevent surprises in the courtroom. No one wants to be caught not understanding some crucial medical issue in a case. Let us help you add spice to your cases to simplify your work.