Congratulations, you now have a pile of medical records to eight inches high or subpoenaed, or your client provided! What now? The purpose of this paper is to store personal injury lawyer for some time and trouble, and hopefully help you to dig up critical information.
like when you're faced with any task, it helps to first have a clear idea of what your goal is, and then work on most of the task to smaller pieces. For a start, even before you get medical records, it will be most helpful to first complete a medical questionnaire client, so you'll have a good idea of what you will need to request records.
A typewritten RECORDS READ FIRST
After you get your bills, your first task is to look at the ER, "History and Physical" records, if there are any, and then search the stack of records to be typed reports. Ignore all the hand-written notes for now. For example, "Discharge Summaries" and "Consult reports" are invaluable because they can quickly display case and show you where you need to look next. Be aware that the "permanent layoff" may simply refer to the patient is "discharged" from one unit to the hospital, such as emergency room (ER) or intensive care unit (ICU), and transferred to floor care and other units within the same hospital. So, there May be more than one "permanent layoff" for the same patient.
Now you want to see if there are "objective" is located in the ER records or consult the report. "Objective" can mean different things to different medical experts, but basically the "objective" refers to the findings that are not under the control of voluntary patient. For example, x-ray refraction is "objective" findings as to determine the actual picture of the fracture.
less obvious "target" is the x-ray of the neck, which shows a "loss of lordosis door" or "leveling the curve of the cervix." Cervical spine in the neck has a natural curve, and the loss of this curve can be shown that the neck was going in muscle spasm, and thus caused a neck that will be corrected.
"cramp" is involuntary tightening of muscles and often associated with a strain / sprain type of injury and pain. Health practitioners such as chiropractors and physiotherapists are trained to feel a muscle spasm when you examine the patient. Specifically, if you see a record of asymmetric spasm, it can be more reliable, "objective" findings. For example, try tensing the muscles of one side of the rear door, and you'll understand how difficult it is to be making such a finding.
now look through the records for all radiology reports are available. Fortunately, these are almost always typed and easy to read. Look for key words such as "acute", which indicate that the injury occurred in a car accident. When looking at a spinal CT or MRI scan report, look for terms that indicate that the nerves are pinched, as a "coup", or something is rubbing against the nerves, because when something is "effaced." Disk bulges or protrusions are obvious, but look for less obvious things, such as "circular cracks," or "torn ring." Simple annular tear May not seem like much, but it's a tear in the spinal disc can be very painful and very difficult to treat . Detection of circular tear is something that would come with his neurologist for further expert opinion.
Much less reliable will be the entry notes that the incident occurred. For vehicle collisions, the doctor will want to know the patients' symptoms during the initial collision, but will not discuss who was wrong. It is still worthwhile to seek the input of records, especially if there is no police report, to at least get a memorable event of the plaintiff in the vicinity at the time of the incident. However, be warned that caregivers who are follow-up care will often only quote and note, with any inaccuracies, early in his chart notes.
Look for things that may require follow-up care. For example, "ORIF" is just jargon for "open reduction internal fixation" surgery to repair a broken bone with surgical screws. So in this case, you would still seek typed records to see if there is something about how long the cast (if any) took place, if the physical therapy began after the cast was removed, and if any adverse reactions to surgical screws. It would not be too unusual to remove a surgical hardware if the cause of inflammation or other types of problems. There should be an indicator of inflammation in such follow-up report, if it existed.
reading the typewritten or even handwritten notes, look for shortcuts that can easily point to what is called. For example, "C / O" in "History and Physical," notes the abbreviation for "complaining". What follows will immediately show the patient's complaints as they existed at that time. Also, the number "2" with what looks like a degree symbol after the abbreviation for "secondary". In other words, for example, pain in the neck "secondary" crash simply means that the start of neck pain after the accident happened.
Other abbreviations refer to the frequency, as when he ordered medication is given. QID means four times a day, TID means three times a day; BID means twice a day and PRN means that the drug, such as pain medication should be taken as often as needed for pain control. "PO" means that the drug should be given usmeno.Mali "c" with line over it means "with" small "s" with lines through it means "without". Do not forget that the medical records of the use of scientific terminology, so that the small triangle means "change" and not "the accused" to the law.
Usually you can just ignore the reams of laboratory data that will inevitably accompany the patient records. However, if for some reason, particularly laboratory values, such as blood sugar (glucose), it is the case, there will usually be a guideline as "normal" values should be. Find the normal values at the top or bottom, or sometimes on a separate page, and then just go back and look at the current values were measured.
Be aware, however, that the laboratory values found in the autopsy report did not exactly like a medical record of a living person. Alcohol, for example, the turmoil in the body after death. Thus, the level of sugar in the blood taken at autopsy after the death of alcohol does not necessarily corresponds to alcohol in the blood as it existed at the time of death. You'll almost certainly need to consult a pathologist for an expert opinion on the post mortem toxicology.
If you encounter an unknown drug or medical conditions, and inspection records, do not be afraid to "Google" it. We are available to us was wonderful and quick access to the full range of medical knowledge, if we simply take a few minutes to research on the Internet. Looking up the situation, such as "carpal tunnel" can not make you an instant expert, but you will at least know whether or not it can be caused by trauma.
B. Handwritten notes
At one point you're probably going to have to deal with handwritten notes. For example, there May be typewritten discharge summary or listing reports, and simply going to have to go through the files looking for documents titled as such. Some practitioners, such as chiropractors, are often hand-written notes only, so you have to try to cross the usually incomprehensible handwriting. Fortunately, even here there should be some useful fields in the file for you to focus na.Prvi the "pain chart" that is schematic representation of the body with coded areas of pain. It is usually filled by the patient, and is an invaluable record of the patient's own "words" which the patient complains of time.
other helpful hand records will be labeled as "soap" note. This is just a standardized "Subjective-Objective-Assessment-Plan" formatu.Liječnik can not keep strictly to the format, but you should be able to make at least the patient's subjective complaints were when first seen, what the objective is found and what diagnosis (assessment) bio.Drugo site to quickly find typed diagnosis from a chiropractor on the checkout pages.
C. MONITORING
By now you should have a good idea of what the medical records, and May there be any need to dig deeper into the hand-written notes. You can begin to decide if you want to hire a legal medical expert, such as a neurologist or orthopedic surgeon, or May you find that you need to subpoena the medical records of more in the first place.
For example, return now and pay particular attention to the "patient history" section of the ER and consultation reports. If there is any indication of pre-existing chronic pain or a previous accident, for example, there May be multiple records of other care that you will need a subpoena before you can contact your specialist or a complete trial lawyers questionable response form. Also, be sure to pay attention to the "current medications" in the ER or the "history and physical" records. If the patient was already on narcotic painkillers, for example, there May be an existing problem that you are not aware of.
In the example above the carpal tunnel, and will have to find out their "Google" search to this syndrome, which often comes on slowly over time from repetitive use of the wrist, such as when writing, but iztraumatskog event. So, now you should look for records of complaints "parasthesias" (unusual sensations such as numbness), in the hands before the incident. You may have to subpoena the previous record in order to determine if the carpal tunnel is caused by work, not the incident.
Before answering the Interrogatories form or hire an expert, there is one last source of relatively cheap information that you should not ignore. Contact your doctor. For example, if you have a prosecutor who is torn ACL in his knee repaired after a crash, contact the surgeon to confirm the surgeon agrees that the accident was the cause of the injury and has created the need for surgery. You can almost always put brief free telephone conference or perhaps a cost of only a few hundred dollars.
Although not strictly related to the records, you should make every attempt to attend a defense medical examination. The defense medical examination can personally observe what is actually tests were carried out by doctors and, more importantly, ensure that the plaintiff responds. Make a narrative report of the results of orthopedic tests that the defense claims the doctor performed.
D. Conclusion
I hope this review helps the next time you review a bunch of seemingly disorganized and illegible medical records. Always keep in mind that everything can be found in medical records is only part of the picture. In the end, you're going to have a medical expert who knows the records and can attest to the opinion on the cause of any injury, the nature and extent of any injury, reasonably necessary, past and future medical expenses associated with injuries.
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