Our Services: Medical records
Analyzing emergency room records for injuries
 A
careful analysis of the medical issues in a claim will ultimately
save the attorney an enormous amount of time and money.
Decisions regarding the management of the case will be influenced
in part by the types of injuries, the profile of the plaintiff,
the plaintiff's response to treatment, and the ability to
refute findings by the physician hired by the other side.
The analysis of medical issues begins with a careful review
of the records generated by the rescue squad and the emergency
department. Med League's nurses have reviewed hundreds of
cases involving medical records of patients involved in
personal injury cases. We believe that the attorney should
never be surprised in the courtroom or during settlement
discussions by potentially negative material in the plaintiff's
medical records. We have found that the pieces of information
listed below are often the crucial keys to a case:
Rescue squad records should
be evaluated to look for:
1. Injuries at the scene: What
did squad members describe as the patient's injuries? Does
this match the injuries observed at the hospital?
2. Use of seat belt or broken
seat belt: Did the squad members comment on whether the
patient was restrained at the time of the accident? Are
there comments regarding a broken seat belt, indicating
that the patient was thrown violently in the car?
3. Description of car, steering
wheel, windshield, seats: A broken steering wheel, a windshield
cracked by a plaintiff's head or broken seats convey the
potential for severe injuries to the plaintiff.
4. Deployment of an airbag:
Airbags can cause powder burns to the face and other acid
injuries, traumatic amputation of thumbs, lower head and
chest injuries.
5. Plaintiff's activities at
the scene: While a plaintiff may not immediately experience
the full effects of his/her injuries, comments such as "Patient
was observed walking around at the scene of the accident"
may imply that the person was not seriously injured.
6. More than one squad involved
in the case: Records may show that a first aid squad and
a mobile intensive care unit were both at the scene of the
accident. Be sure that all the records of both squads are
obtained.
7. Behavior of the plaintiff
and treatment en route to the ER: What was the plaintiff's
condition during the ambulance trip? What were the medical
interventions provided during the transport? (Administration
of oxygen is common.)
8. Documentation that the squad
took photos at the scene: Copies of these pictures should
be obtained before this evidence disappears.
Emergency Room Records should
be reviewed to determine:
1. Who first saw the patient:
Usually a triage nurse will see the patient before the patient
is officially checked in to the ER.
2. How did the patient arrive
at the ER: by car or by squad?
3. When did the patient go
to the ER in relation to the accident: Was the patient seen
in the ER the same day or was the visit delayed?
4. If the visit did not occur
the same day as the accident, is there any reason indicated
for why the patient went to the ER: Does the record say
"Patient instructed to go to ER by his attorney?"
5. Complaints of the plaintiff:
Were these the same complaints that were documented by the
squad?
6. Injuries: If the patient
was rear-ended, are low back or cervical spine symptoms
documented? (These symptoms may not occur until 24 hours
after the accident.) Were lacerations severe enough to be
sutured? What x-rays were taken and what did they show?
7. Use of seat belt: Is the
patient described as having been restrained at the time
of the accident? (We have seen that this fact is often changed
in subsequent records. At times the unrestrained (at the
time of the accident) patient claims to have had on a seat
belt when giving a history of the accident to a treating
physician.)
8. Loss of consciousness: Did
the patient report a loss of consciousness at the accident
scene?
9. Chronic medical conditions:
Look for seizure disorder and transient ischemic attacks
(potential for raising questions of liability), arthritis
(pre-existing condition), deafness (potential for raising
questions on liability), hypoglycemia (drop in blood sugar
which may result in lowered attention and may contribute
to causing an accident) and glaucoma or cataracts (decreased
vision may contribute to the accident).
10. Medications taken on a
routine basis: Look for sedatives and narcotics, which may
cause drowsiness. Narcotics or other pain relievers raise
questions about pre-existing conditions. Eye drops raise
issues concerning visual acuity. A history of being on antidepressants
may be significant if the patient claims to have become
depressed as a result of the accident (as a new condition
instead of acknowledging the existence of a pre-existing
condition.)
11. Positive alcohol smell:
This may be written as "+ETOH" or "AOB"
(alcohol on breath). Some people will misrepresent the amount
of alcohol they consumed. Many will never admit to having
had more than 2 beers.
12. Blood alcohol level: Know
your state's legal definition of intoxication.
13. Drug screen: If the patient's
blood tested positive for drugs, look at the ER record to
determine if any narcotics were given in the ER. Then check
the time on the blood test to see when the blood was drawn
- before or after the narcotic was given.
14. Level of consciousness
(LOC): Did the patient report a loss of consciousness? What
was the patient's LOC in the ER? A patient described as
A&OX3 knew who he was, where he was and the date. A&Ox4
means all of the above, plus the patient remembered recent
events leading up to the ER visit. This is less commonly
used than A&Ox3.
15. Glasgow Coma Scale: A scale
of 15 is the highest possible score. A patient can be dead
and have a score of 3.
16. What did nurses observe
about the patient? What symptoms did the patient experience
while in the ER? Was the patient's behavior congruent with
the injuries, or did the nurse document symptoms that would
cast doubt on the seriousness of the injuries?
17. Were the appropriate x-rays
taken based on the plaintiff's complaints?
18. Were x-rays read by the
radiologist or only by the ER doctor initially?: All ER
x-rays must be 'over-read' by a radiologist later.
19. Did the patient receive
discharge instructions? Were they written or oral? Did the
plaintiff sign that instructions were given?
20. Was the plaintiff instructed
to seek care from the PMD (Primary Medical Doctor)? Was
this done?
21. Was a prescription given?
What type of medication was it?
Careful review of the records
created by the rescue squad and emergency department staff
will give you a firm foundation for understanding the injuries
the plaintiff sustained. This information can be used to
substantiate or refute later claims of damages resulting
from an accident.
See also:
Organizing medical records
Summarizing medical records
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