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How to read and interpret medical records of personal injury cases

Congratulations, you now have an 8-inch medical record that you can summon or provide to your customers! What should we do now? The purpose of this article is to save the personal injury lawyers some time and anxiety and hopefully help you to mine the key information.

When you face any task, first of all have a clear idea of ​​what your goals are, and then work from the largest part of the task to the finer parts. First of all, even before getting a medical record, first ask the patient to fill out a medical questionnaire so that you can have a good understanding of which records you need.

A. First read the typical record

After obtaining the record, the first task is to view the ER "history and actual" record (if any), and then search the record stack for any printed report. Now ignore all your handwritten notes. For example, "unloading summary" and "consulting report" are invaluable because they can quickly summarize cases and point you to the next step. Please note that the "Summary of discharge" may simply refer to a unit in the hospital (such as an Emergency Room (ER) or Intensive Care Unit (ICU)) being "discharged" and transferred to a ground care or other unit in the same hospital, so the same patient There may be more than one "Summary of discharge"

You now need to see if there are any "objective" results in the ER records or the consultation report. "Targets" may mean different things to different medical experts, but basically "objective" refers to discoveries that are not controlled voluntarily by patients. For example, a fractured X-ray is an "objective" finding because it shows the actual image of the fracture.

Less obvious "objective" is the X-ray of the neck showing "cervical lordotic lordosis" or "corrected neck curve." The cervical spine of the neck has a natural curve, and loss of this curve may indicate that the neck enters a muscle spasm, resulting in an involuntary neck straightening. 19659002] "Skull" is an involuntary tightening of muscles. It is often accompanied by strain/sprain injuries and pain. Medical practitioners such as chiropractors and physiotherapists are trained in muscle cramps when they are examined, especially if You will see the asymmetry of the asymmetry, which may be a more reliable "objective" discovery. For example, try to tighten the muscles on the side of the back of your neck, and you will realize how difficult it is to create such a flaw. .

You Laugh Now Please review any available radiology reports. Fortunately, these are almost always typing and easy to read. Finding keywords such as "Acute" indicates that the injury occurred in a car crash. When looking at a CT or MRI scan of the spine, look for terms that indicate that the nerves are being squeezed, such as “shock,” or something is rubbing the nerves as if it were “wiped off.” Disc herniation or protrusion is obvious, but it will also look for less obvious things, such as "annular cracks" or "torn rings." A simple ring tear may not seem like much, but this disc tear can be very painful and difficult to treat. The discovery of a circular tear is further advice from your neurological expert.

An explanation of how intakes of events occur is less reliable. For a collision of vehicles, the doctor will want to know the initial symptoms of the patient during the crash, but will not care about who is at fault. At least let the plaintiff recall the incident at the time of the incident, especially if there is no police report, it is still worthwhile to find the record of smoking. However, it should be cautioned that caregivers conducting follow-up visits often refer to intake instructions and any inaccurate information when starting their own chart notes.

Look for things that may require follow-up care. For example, "ORIF" is just a term used for "open reduction and internal fixation" surgery to repair fractures with surgical screws. Therefore, in this case, you will continue to search for typing records to see if there is anything about how long an actor (if any) has existed; if a physiotherapy process starts after the casting is removed; and if the screw is on There are any adverse reactions. If it causes inflammation or other types of problems, some surgical hardware must be removed and less common. In the follow-up report there should be signs of inflammation indicating whether it is present.

When reading typed or even handwritten notes, look for the abbreviations that can be easily referenced. For example, "C / O" in "Historical and Physical" notes is a shorthand for "Complaints." The following content will immediately summarize the patient's complaint at that time. Similarly, the number "2" represents the sign after "degrees." In other words, for example, neck pain “secondary to a car accident” simply means that neck pain occurs after a car accident

Other abbreviations refer to frequency, such as when ordered drugs should be administered. QID means four times a day; TID means three times a day; BID means twice a day, and PRN means that drugs like pain medicines should be taken as often as needed to control pain. "PO" means oral medication. A small "c" with a line means "with" and a small "s" means "no." Remember that medical records use scientific terms, so a small triangle means "change" rather than "defendant" in the law.

In general, you can ignore laboratory data that inevitably accompany patient records. However, if for some reason a particular laboratory test value (such as blood glucose (glucose)) is important for this case, there is usually a criterion for what the "normal" value should be. Find these normal values ​​at the top or bottom of the page, or sometimes find these normal values ​​on a separate page, then go back and see what the actual measurements are.

But please note that laboratory records are not exactly the same as the medical records of living people at autopsy reports. For example, alcohol will ferment in the body after death. Therefore, the blood alcohol content at postmortem autopsy does not necessarily coincide with the presence of blood alcohol at the time of death. You almost certainly need to consult a pathologist to get expert advice on post-mortem toxicology.

If you encounter an unfamiliar drug or medical condition while viewing a record, don’t be afraid to “Google” it. If we only spend a few minutes researching on the Internet, we can get wonderful and instant comprehensive medical knowledge. Looking at a condition such as "carpal tunnel" may not make you an instant expert, but you can at least know if it can be caused by trauma.

B. Handwritten notes

At some point, you may need to deal with handwritten notes. For example, there might not be a typing summary or import report that you typed. You only need to look at the record to find the file with the title. Some practitioners, such as chiropractors, usually only have handwritten notes, so you will have to try to pass handwriting that is usually not understandable. Fortunately, even here, there should be several useful areas for your attention. The first is a "pain map", which is a schematic outline of a body coding area. This is usually done by the patient, which is an invaluable record for the patient's own "words" when the patient is complaining.

Other useful handwriting records will be marked as "SOAP" notes. This is just a standardized "subjective goal assessment plan" format. The doctor may not strictly follow the format, but you should at least be able to determine the patient's subjective complaint the first time you see it; what objective results have been found; and what the diagnosis (evaluation) is. Another place where you can quickly find the chiropractor diagnosis type is on the settlement page.

C. Follow-up

Now, you should have a clear understanding of what is in the medical record, and it may not be necessary to dig into handwritten notes. You can start deciding whether to hire medical legal experts, such as neurologists or plastic surgeons, or you may find that you need to first summon more medical records.

For example, go back now and pay special attention to the “patient history” section of the emergency room and consultation report. For example, if there are any signs of pre-existing chronic pain or previous accidents, there may be more records from other care providers that you need to call in order to contact an expert or fill out a judicial advisor form and ask for a response. In addition, be sure to note the ER's "current medication" section or "history and body" record. For example, if a patient has already used an anesthetic pain killer, there may be a pre-existing problem that you do not know.

In the above example of a carpal tunnel, you would find from your "Google" search that this is a syndrome that often occurs gradually due to repetitive use of the wrist, such as typing, not trauma Sexual events. Therefore, you now need to look for complaints of “feeling numbness” (abnormal feelings, such as numbness) recorded in the hands before the incident. You may need to summon previous records to find out that the carpal tunnel was caused by work, not by the incident.

Before you answer the form to ask or hire an expert, you should have the last relatively cheap source of information not to ignore. Contact a treating doctor. For example, if your plaintiff has repaired the knee tear ACL after a collision, contact the surgeon to confirm that the surgeon agrees that the car accident was the cause of the injury and created a surgical need. You can almost always set up a short toll-free conference call, or it may only take a few hundred dollars.

Although there is no strict relationship with the record, you should make every effort to participate in the defense medical examination. In the defense medical examination, you can personally observe the actual test performed by the doctor. More importantly, please see for yourself how the plaintiff reacted. Check the narrative report for the results of the orthopaedic examination claimed by the defense doctor.

D. Conclusion

I hope this review will help you to review a bunch of seemingly untidy medical records next time. Always remember that whatever you find in a medical record is only part of the picture. Ultimately, you need a medical expert who knows the records, and you can witness the nature of each injury, the nature and extent of each injury, and the medical expenses that are necessary and necessary for the past and future related to the injury.

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