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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