You may be a plaintiff or defense attorney dealing with personal injury, medical malpractice, or toxic tort cases and you will have to request the patient medical record for review and analysis. In any of these cases, medical records are an important component and provide clear evidence of any departure from the standard of care. Therefore, you need to make sure that you have received a complete set of medical records relevant to the case. Let us consider the hospital record and the documentation that comprises a patient’s hospital record.
- Patient identification sheet: This is the initial documentation that is made during the admission of the patient, during discharge, and when the medical records custodian certifies that the medical chart is complete. It is after this that the medical chart is filed in the hospital records database. This is a very important document that contains the background information of the patient including employment details, insurance data and admitting diagnosis. When the patient is discharged, all other details are filled in such as final diagnosis, complications suffered, surgical procedures performed. This record will be verified by an attending physician who certifies that the chart has been checked to ensure that it meets all state and federal requirements.
- History and physical examination records: It is mandatory for hospitals to complete history and physical examination on every patient who is admitted and maintain that record. The history comprises a detailed description of the cause of the injury/illness. Apart from this, other details recorded include the patient’s disabilities, work history, pre-existing symptoms, previous medical care and chronic medical problems.
- Physician’s progress records: This comprises a chronological record of changes or developments in the patient’s condition. Nurses that attend the patient may also include their notes along with the physician’s progress records, or maintain separate notes. These include general observations such as:
- Observations regarding the patient’s physical, mental and emotional conditions
- Medications administered, dosages, time of administration and method of administration as advised by the physician
- Details regarding urgent calls made to physicians and sudden changes in the condition of the patient
- Vital signs including blood pressure, respiration rate and pulse taken at intervals ordered by the physician
- Patient’s food intake, bladder and bowel function
- Discharge note with details of the plan for home care and follow-up
- Consent forms: These may include consent for anesthesia, surgery, surgical sterilization, post-mortem examinations and so on.
- Lab reports: X-rays and ECGs and reports of diagnostic studies that are added to the patient’s medical chart.
- Physician order sheets: Physician instructions to nursing staff regarding patient care that are provided on an order sheet. These may include instructions regarding medications and intravenous fluids that are to be administered; diet; lab tests; and times at which the vital signs are to be taken.
- Consultation reports: These comprise the findings and opinions of consulting physicians who assist in the patient’s care and management. These may either be separate reports or included as a note along with the attending physician’s progress notes.
- Discharge summary: This is the attending physician’s summary of the patient’s entire course of hospitalization and offers a clear overview of the entire medical encounter. The discharge summary usually contains a recounting of the admitting history and physical examination, the patient’s hospital course, diagnoses, details of diagnostic studies, healthcare services provided, and the final outcome. Since this summary is to be dictated and transcribed on the day the patient is discharged, this date can be found in the lower left or right of the document.
To ensure that you have a complete set of medical records and that they give a complete and consistent narrative of the patient’s hospital stay, have the records reviewed by a medical record review company with excellent standing in the industry. A comprehensive medical record review will help identify inconsistencies or gaps that signify medical negligence, and the records will serve their purpose by helping you prove your case at trial.