What Role Do Medical Records Play in an Elder Abuse Case?

by | Last updated on Sep 7, 2023 | Published on Mar 10, 2023 | Medical Record Review

An elder abuse case involves an injury, and therefore just as in any personal injury case, it calls for the review of the injured person’s medical records and the use of medical record retrieval services. So, what constitutes elder abuse? It signifies any knowing, negligent or intentional act by a caregiver or any other person, which results in harm or a serious risk of harm to a dependent adult.

Different Types of Elder Abuse

The types of abuse can be:

  • Physical: This involves threatening to inflict or actually inflicting an injury or physical pain on an elderly person, or not providing them with their basic needs.
  • Emotional: Here distress, mental pain, or anguish is inflicted on the vulnerable person through physical or verbal actions.
  • Sexual: Any kind of non-consensual sexual contact.
  • Exploitation: Misuse or concealment of funds or assets or illegally securing an elder’s funds, property and assets.
  • Neglect: Refusal or failing to provide healthcare, food, shelter, and protection to a weak elderly person.
  • Self neglect: This signifies the behavior of the elderly person who threatens his/her own safety and health. They deprive themselves of the adequate amount of food, water, shelter, clothing, personal cleanliness, necessary medications, and safety precautions.
  • Abandonment: In this type of abuse, the elderly person is deserted by people who are responsible for their care and custody.

How Medical Records and Medical Record Review Are Important

In most elder abuse cases, some injury or illness may be involved, which highlights the significance of medical records. These cases can be civil or criminal cases, and involve concerns such as pressure ulcers and the failure on the part of the caregiver to turn the patient to prevent such wounds. In other cases, it may be injuries caused by slip and fall and the important question is whether the staff had ensured efficient safety measures to prevent such injuries from happening.

Medical record review is important because it helps determine whether / how the patient’s medical conditions may have contributed to their conditions. It also helps decide whether there were any breaches in the standard of care. So, what are the important medical records that need to be retrieved so that a legal case chronology can be prepared for the attorney’s use? These include, lab tests and results, physicians’ notes, and many others.

Check out our blog for a detailed list of the medical records needed to identify nursing home abuse and elder abuse.

Prosecuting attorneys necessarily need the hospitalization records and emergency department records when the abuse was first identified. Diagnostic records, physician notes, records of any emergency medical services provided or ambulance records, lab tests and radiographic tests done during the hospitalization, medical records with descriptions of the wounds and their size, social work notes, psychiatric evaluations done during the hospitalization, medical photos, medication and treatment administration records, are all very significant from the point of view of an elder abuse case. In fact, the medical records many months/years prior to when the abuse was identified and those months/years after the abuse was detected may be helpful. Nursing records perhaps contain the best documentation of pressure ulcers, the person’s appearance, skin care and such other important aspects. Social work notes are also crucial because these contain evidence regarding the victim’s admission to other healthcare facilities with falls, fractures and other injuries.

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What a Medical Review Expert Will Be Looking for

A comprehensive medical record analysis would focus on the following documentation:

  • Bruises, bedsores, cuts or other wounds that cannot be explained
  • Unexplained dislocations, internal injuries, fractures
  • Loss of weight or appetite
  • Poor personal hygiene and disheveled appearance
  • Abrupt mood changes such as getting agitated, becoming withdrawn, or not communicating
  • Symptoms of fearfulness, confusion, anxiety or depression
  • Not willing to talk about the nursing home, their staff, or the care received

Medical Review Services Could Be Supportive for Attorneys

Given the large-volume medical documentation and unstructured medical data, attorneys are best served if they partner with a reliable medical record review company. One of the most challenging responsibilities when it comes to reviewing medical records from various medical care facilities is medical record organization.

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The medical record review process can be made more efficient and speedier if attorneys clearly state their requirements to the expert reviewers. Once the requirements are clear, the review team can quickly extract the relevant evidence from the medical records and prepare the medical case summary and report. With a well-written medical review report, attorneys can prepare their case well and the report can be used throughout the trial.

To obtain the due compensation for the abused elder, attorneys must be able to prove the abuse using convincing, concrete evidence. A medical record review company can provide this crucial evidence, and support the attorney throughout the lifetime of the case. Compensation can be claimed for the medical bills incurred because of the abuse, injury, mental pain and suffering experienced, cost of transferring the injured elder to another nursing home, and financial losses due to any financial abuse.

Disclaimer: The information in the above blog is sourced from reliable internet resources and is meant for informative purposes only. For a professional legal opinion, contact a personal injury attorney.

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