Personal injury attorneys frequently handle cases that involve injuries which require emergency department treatment. Here are 10 questions you should ask when you look at these records. Can’t read the records? Ask for our help. We have vast experience in interpreting emergency department records.

1. Was a blood alcohol level (BAL) drawn? Know the legal definition of intoxication in the state where the accident occurred. Was there a positive alcohol smell noted? This may be written as “+ETOH” or “AOB” (alcohol on breath). Few people will ever admit to having more than two beers prior to driving a motor vehicle.
2. Was a drug screen done? If the patient’s blood tested positive for drugs, look at the rescue squad and ED records to determine if narcotics were given. If the patient was treated with narcotics after the accident, check the time the drug screen blood test was drawn. This will enable the reviewer to determine if the blood was drawn before or after narcotics were given.
3. What was the patient’s level of consciousness (LOC)? What was the patient’s LOC in the ED? A patient described as A&Ox3 (“alert and oriented times three”) knew who she was, where she was and the date. A&Ox4 means all of the above, plus the patient remembered recent events leading up to the ED visit. A&Ox4 is less commonly used than A&Ox3.
4. What was the Glasgow Coma score? A score of 15 is the highest possible score. A patient can be dead and have a score of 3.
5. What did nurses observe about the patient? What symptoms did the patient experience while in the ED? Was the patient’s behavior consistent with the injuries, or did the nurse document symptoms that would cast doubt on the seriousness of the injuries?
6. Were the appropriate x-rays taken based on the patient’s complaints?
7. Were x-rays read by the radiologist or only by the ED doctor initially? All ED x-rays must be “over read” by a radiologist later.
8. Did the patient receive discharge instructions? Were the discharge instructions written or oral? Did the patient sign that instructions were given?
9. Was the patient instructed to seek care from the PMD (primary medical doctor)? Was this done?
10. Were prescriptions given to the patient at discharge? If so, what type of medications were prescribed?

Source: Analyzing Medical Records, Medical Legal Aspects of Medical Records, Second Edition, 2010, Lawyers and Judges Publishing

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