How To Do Medical Record Analysis Of Emergency Room Records

March 7, 2022| Last modified on August 27th, 2022 Julie Clements 0 Comments

Medical Record Analysis

A thorough medical record analysis of emergency room records is essential to understand the patient’s health issue and promote improved patient care. ER records document all patient encounters such as laboratory, radiology, and other diagnostic test results. Medical records constitute strong legal evidence as well, and in a personal injury case provide a detailed picture of the injuries and how they impact the plaintiff’s life. They help attorneys to establish that the injuries contributed to the medical bills, loss of income and other damages that might have to be dealt with later. In short, emergency room records are an integral part of the litigation process and help to accurately quantify the compensable damages.

Types of ER Records to be Analyzed

  • Handwritten
  • Dictated/transcribed
  • Scribed
  • Templated
  • Electronic medical records

Medical Record Analysis – Steps Involved

The analysis or review involves comprehensive evaluation of the medical chart of a patient. The entries in the medical records are carefully reviewed, interpreted, and analyzed.

  • Medical records from various sources are received and organized in the correct order
  • Identifying what caused the alleged injuries or damages
  • Identifying the medical records that are missing, which may be vital at some stage of the case
  • Preparing a medical case chronology and summary
  • Preparing concise medical reports

Evaluation of medical records

Attorneys decide the legal course of the case by assessing:

  • Types of injuries
  • Profile of the plaintiff
  • Plaintiff’s response to the treatment received at the emergency room
  • The arguments of defense of the physician hired by other side to refute the claims of plaintiff

Any missed or misinterpreted information during the process of medical record review are loop holes and can be detrimental to the case.

Attorneys have to look for the below-mentioned information also while analyzing ER records:

  • The description of the injury by the emergency squad
    The emergency squad’s description of the patient’s injuries has to be cross-verified with the injuries observed at the hospital.
  • The first person who saw the patient 
    A triage nurse is the first person who sees the injured victim before the patient is admitted to the hospital. During the litigation process, it is essential to record the statement of the first person who saw the patient.
  • The means by which the patient arrived at the ER
    Emergency room records have to be reviewed to determine how the patient was brought to the ER, by car or by the rescue squad.
  • The date of arrival of the patient at ER
    It is important to know the date of the patient’s visit to the ER. This helps to determine whether there was any delay in receiving the required treatment.
  • The reason for the delayed visit at the ER
    There will be the specific mentioning of the delayed arrival of the patient in the ER records. Check whether the record says that the patient was instructed to go to the ER by his attorney.
  • Complaints reported by the plaintiff
    Check whether the complaints of the plaintiff match with the data documented by the rescue squad.
  • Nature of the injury
    If the patient was rear-ended at the time of accident, low-back and cervical symptoms are documented. However, these symptoms might not occur until 24 hours after the accident. In such circumstances, the nature of injury can throw light upon the medical condition that might arise later. This can be determined with the help of X-ray results. The severity of the lacerations will also be added in the ER records.
  • Use of seatbelt
    In road accidents, it is vital to check whether the patient was restrained at the time of the accident. This is noted by the treating emergency physicians while recording the statement of the patient.
  • Loss of consciousness
    It is important for attorneys to know whether the patient was conscious at the accident scene. Emergency room physicians and rescue squad enter this data in the ER records.
  • Underlying medical conditions of the patient
    It is important to look for chronic medical conditions of the patient. Check whether the accident occurred due to the presence of these conditions. For example, seizure disorders, transient ischemic attacks or arthritis potentially raise questions of liability.
  • Daily medication of the patient
    The history of medicines taken by the plaintiff gives an idea about his/her existing conditions. Based on this data, attorneys can frame arguments without loopholes.
  • Presence of alcohol
    Alcohol on breath is represented as “+ETOH” or “AOB” in ER records.  Also, the level of alcohol in the blood will also be reported. These data help attorneys to know whether the alcohol levels are within the state’s legal level of intoxication.
  • Drug screen
    If the patient is tested positive for narcotics, then the time with which the blood was drawn for test can help attorneys determine if the narcotics were given in the ER.
  • Clinical observations of the nurses
    The symptoms experienced by the patient are recorded by nurses present in the ER. Attorneys have to verify that the patient’s response to the injury is congruent with the statements reported.
  • The prescription given to the plaintiff
    It gives an insight into the medication provided to the patient. This data acts as a firm foundation to understand the severity of the injury sustained by the plaintiff.

ER records provide:

  • Direct evidence of the injuries This is specifically paramount in personal injury cases where in the burden of proof lies with the plaintiff. It helps attorneys to understand the treatment strategy and the severity of the injury. The documentation of pain is a strong evidence to show the required future treatment.
  • Proof of damages
    ER records legally substantiate the claims the plaintiff is seeking from insurance companies. Devoid of the proof, insurance companies can deny the claims by arguing that there were no serious injuries, even when you have not received necessary treatment due to financial constraints or transportation issues.
  • Calculation of financial impact of the injuries
    ER records indicate the worth of your injury. It enables attorneys to correctly calculate the expenses of hospital stays, surgeries, rehabilitation and clinical prescriptions. Thus, the financial impact of the injuries can be estimated by taking into consideration the medical treatment the plaintiff has received immediately in emergency rooms. The mental impact of the victim can also be analyzed with the help of ER records.

ER records serve as:

  • Direct evidence of the injuries caused to the plaintiff
    This is specifically paramount in personal injury cases wherein the burden of proof lies with the plaintiff. It helps attorneys to understand the treatment strategy and the severity of the injury. The documentation of pain is a strong evidence to show the required future treatment.
  • Proof of damages
    ER records legally substantiate the claims the plaintiff is seeking from insurance companies. Devoid of the proof, insurance companies can deny the claims by arguing that there were no serious injuries, even when the plaintiff has not received necessary treatment due to financial constraints or transportation issues.
  • Calculation of financial impact of the injuries
    ER records help attorneys to correctly calculate the expenses of hospital stays, surgeries, rehabilitation and clinical prescriptions. Thus, the financial impact of the injuries can be estimated by taking into consideration the medical treatment the plaintiff has received immediately in the ER. The mental impact on the victim can also be analyzed with the help of ER records.

Medical records are the lifeline of a case. There is high level of complexity in medical cases involving emergency departments. Attorneys and legal firms handling such cases can benefit from the service of a medical records review company that provides accurate review of ER and other medical records. It should be noted that medical information in the medical records not only prove monetary damages but also proves non-economic damages like mental anguish, loss of enjoyment of activities, and the worsening of prior injuries. Error-free analysis of medical records can considerably reduce the amount of time and money that has to be invested in computing the claims.

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