A Review of Emergency Room Records at Rural Millard Fellmore Memorial Hospital

A conscientious analysis of the medical issues in a claim volition ultimately relieve the attorney an enormous amount of time and money. Decisions regarding the management of the case volition be influenced in part by the types of injuries, the contour of the plaintiff, the plaintiff's response to treatment, and the ability to refute findings past the dr. hired by the other side. The analysis of medical issues begins with a conscientious review of the records generated by the rescue squad and the emergency department. Med League'south nurses take reviewed hundreds of cases involving medical records of patients involved in personal injury cases. We believe that the chaser should never be surprised in the courtroom or during settlement discussions by potentially negative material in the plaintiff's medical records. Nosotros accept found that the pieces of information listed below are oft the crucial keys to a example:

Rescue team records should exist evaluated to look for:

1. Injuries at the scene: What did squad members describe every bit the patient'south injuries? Does this match the injuries observed at the hospital?

2. Use of seat belt or cleaved 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 chugalug, indicating that the patient was thrown violently in the car?

3. Description of car, steering bicycle, windshield, seats: A cleaved steering wheel, a windshield croaky by a plaintiff's head or cleaved seats convey the potential for astringent injuries to the plaintiff.

4. Deployment of an airbag: Airbags tin cause pulverization burns to the confront and other acid injuries, traumatic amputation of thumbs, lower head and chest injuries.

5. Plaintiff'due south activities at the scene: While a plaintiff may not immediately experience the full furnishings 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 1 squad involved in the case: Records may testify that a kickoff aid squad and a mobile intensive care unit were both at the scene of the accident. Be certain that all the records of both squads are obtained.

7. Beliefs of the plaintiff and treatment en road to the ER: What was the plaintiff'southward condition during the ambulance trip? What were the medical interventions provided during the transport? (Administration of oxygen is common.)

viii. Documentation that the squad took photos at the scene: Copies of these pictures should be obtained before this prove disappears.

Emergency Room Records should be reviewed to determine:

one. Who outset saw the patient: Usually a triage nurse volition encounter the patient earlier the patient is officially checked in to the ER.

two. How did the patient go far at the ER: past motorcar or by squad?

3. When did the patient get to the ER in relation to the blow: Was the patient seen in the ER the aforementioned day or was the visit delayed?

4. If the visit did non occur the aforementioned twenty-four hour period equally the blow, 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 chaser?"

5. Complaints of the plaintiff: Were these the same complaints that were documented by the squad?

6. Injuries: If the patient was rear-concluded, 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 10-rays were taken and what did they show?

7. Utilize of seat belt: Is the patient described as having been restrained at the fourth dimension of the accident? (We have seen that this fact is often changed in subsequent records. At times the unrestrained (at the time of the blow) patient claims to have had on a seat belt when giving a history of the accident to a treating md.)

eight. Loss of consciousness: Did the patient study a loss of consciousness at the blow 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 claret 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: Await for sedatives and narcotics, which may cause drowsiness. Narcotics or other pain relievers heighten questions about pre-existing conditions. Center drops raise issues apropos visual vigil. A history of existence on antidepressants may exist meaning if the patient claims to accept become depressed as a result of the accident (as a new condition instead of acknowledging the existence of a pre-existing status.)

eleven. Positive alcohol smell: This may exist written as "+ETOH" or "AOB" (booze on jiff). Some people will misrepresent the amount of alcohol they consumed. Many volition never admit to having had more than 2 beers.

12. Claret booze level: Know your state'southward legal definition of intoxication.

13. Drug screen: If the patient's blood tested positive for drugs, look at the ER tape to determine if any narcotics were given in the ER. Then check the time on the blood test to run across when the claret was drawn – before or after the narcotic was given.

fourteen. Level of consciousness (LOC): Did the patient study 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 in a higher place, plus the patient remembered contempo events leading upwards to the ER visit. This is less commonly used than A&Ox3.

xv. Glasgow Coma Scale: A scale of xv is the highest possible score. A patient tin 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'south behavior coinciding with the injuries, or did the nurse document symptoms that would bandage doubt on the seriousness of the injuries?

17. Were the advisable,taken based on the plaintiff's complaints?

eighteen. Were x-rays read by the radiologist or just by the ER physician initially?: All ER ten-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 intendance from the PMD (Primary Medical Dr.)? Was this done?

21. Was a prescription given? What type of medication was it?

Careful review of the records created by the rescue team and emergency department staff will give you lot a firm foundation for understanding the injuries the plaintiff sustained. This data can be used to substantiate or abnegate afterwards claims of damages resulting from an accident.

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Source: https://www.medleague.com/knowledge-base/analyzing-emergency-room-records/