Congratulations, you now have a stack of curative records eight inches high that you either subpoenaed or your client provided! What now? The purpose of this report is to save the personal injury attorney some time and anxiety, and hopefully, help you to dig out the key information.
As when you are confronted with any task, it helps to first have a clear idea of what your objective is, and then work from the largest part of the task down to the finer parts. To begin, and even before you gather the curative records, it will be most helpful to first have the client unblemished a curative questionnaire, so that you have a good idea of what records you will need to request.
Personal Injury Lawyer
A. Read The Typewritten Records First
How To Read and elucidate healing Records In Personal Injury Cases
Once you gather the records, your first task is to look at the Er "History and Physical" records, if there are any, and then to quest your stack of records for any typewritten reports. Ignore all handwritten notes for now. For example, "Discharge Summaries" and "Consult Reports" are invaluable because they speedily summarize the case and point out for you where you will need to look next. Be aware that a "discharge summary" may simply refer to a outpatient being "discharged' from one unit in the hospital, such as the emergency room (Er) or laberious care unit (Icu), and transferred to floor care or some other unit within the same hospital. So there may be more than one "discharge summary' for the same patient.
You will now want to see if there are any "objective" findings in the Er records or consult reports. "Objective" can mean separate things to separate curative experts, but basically "objective" refers to findings which are not under the voluntary operate of the patient. For example, an x-ray of a fracture is an 'objective" looking since it will show an actual photograph of the fracture.
Less obviously "objective" is an x-ray of the neck that shows a "loss of cervical lordosis" or a "straightening of the cervical curve." The cervical spinal column in the neck has a natural curve, and a loss of this curve may show that the neck was going into muscle spasm and thereby caused the neck to involuntarily straighten.
"Spasm" is the involuntary tightening of muscles and is frequently associated with strain/sprain type injuries and pain. Healthcare practitioners, such as chiropractors and corporeal therapists, are trained to feel muscle spasm when they inspect a patient. In particular, if you see a notation of asymmetric spasm, this might be a more reliably "objective" finding. For example, try tensing the muscles of just one side of the back of your neck, and you will perceive just how hard it would be to develop such a finding.
You should now look straight through the records for anything radiology reports are available. Fortunately, these are practically always typewritten and easy to read. Look for key words such as "acute" which indicate that the injury happened while the car crash. When looking at a spinal Ct or Mri scan report, look for terms that indicate that the nerves are pinched, such as with an "impingement," or that something is rubbing up against the nerves as when something is "effaced." Disc bulges or protrusions are obvious, but also look for less obvious things, such as an "annular fissure" or a "torn annulus." A easy annular tear may not seem like much, but this tear in the spinal disc can be quite painful and very difficult to treat. A looking of an annular tear is something to bring up with your neurology expert for a additional opinion.
Much less reliable will be the intake notes as to how the incident happened. For a vehicle collision, the physician will want to know the patients introductory symptoms while the crash, but will not be involved with who was at fault. It is still worthwhile to look for in the intake records, particularly if there is no police report, to at least get the plaintiff's recollection of events close to the time of the incident. However, be forewarned that the caregivers who do follow-up care will frequently just quote the intake notes, along with any inaccuracies, when starting their own chart notes.
Look for things that may want follow-up care. For example, "Orif" is simply jargon for "open allowance internal fixation" surgical operation to fix a broken bone using surgical screws. So in that instance, you would continue to quest the typewritten records to see if there is anything about how long the cast (if any) was in place; if a procedure of corporeal therapy was started after the cast was removed; and if there were any adverse reactions to the surgical screws. It would not be too unusual to have to take off some of the surgical hardware if it was causing inflammation or some other sort of problem. There should be some indication of such inflammation in the follow-up reports if it existed.
While reading the typewritten or even handwritten notes, look for abbreviations which may beyond doubt indicate what is being referred to. For example, "C/O" in the "History and Physical" notes is shorthand for "complaining of." What follows will immediately summarize the patient's complaints as they existed at that time. Similarly, a estimate "2" with what looks like a degree seal after it stands for "secondary to." In other words, for example, neck pain "secondary to" a car emergency simply means that the onset of neck pain happened after a car accident.
Other abbreviations refer to frequency, such as when an ordered medicine is to be given. Qid means four times a day; Tid means three times a day; Bid means twice daily, and Prn means that the medication, such as pain medicine, is to be taken as often as needed for pain control. "Po" means that the medication is to be given orally. A small "c" with a line over it means "with" and a small "s" with a line over it means "without." Remember that curative records use scientific terminology, so a small triangle means "change," and not "defendant," as it would in law.
Ordinarily, you can just ignore the reams of laboratory data that will inevitably accompany a patient's records. However, if for some surmise a singular lab value, such as blood sugar (glucose), is leading to the case, there will regularly be a guideline as to what "normal" values should be. Find these general values at the top or lowest of the page, or sometimes on a isolate page, and then just go back and look at what the actual measured values were.
Be aware, however, that the lab values found in an autopsy report are not exactly like the curative report of a living person. Alcohol, for example, ferments in the body after death. So a blood alcohol level taken on autopsy after death does not necessarily correspond with the blood alcohol as it existed at the time of death. You will practically beyond doubt need to consult a pathologist for an expert view on the post mortem toxicology.
If you run into an unfamiliar medication or curative condition while reviewing the records, do not be afraid to "Google" it. We have ready to us marvelous and instant way to a whole range of curative knowledge, if we simply take a few minutes to explore it on the internet. looking up a condition, such as "carpal tunnel" may not make you an instant expert, but you will at least know either or not it can be caused by trauma.
B. Handwritten Notes
At some point you are probably going to need to deal with the handwritten notes. For example, there may be no typewritten extraction summaries or intake reports, and you are simply going to have to go straight through the records looking for documents entitled as such. Some practitioners, such as chiropractors, frequently have handwritten notes only, so you will have to try to wade straight through the regularly unintelligible handwriting. Fortunately, even here there should be a integrate of helpful areas in the file for you to focus on. The first is the "pain diagram," which is a schematic frame of a body with coded areas of pain. This is regularly filled out by the patient, and is an invaluable record, in the patient's own "words," of what the outpatient was complaining of at the time.
The other helpful handwritten records will be labeled "Soap" notes. This is just a standardized "Subjective-Objective-Assessment-Plan" format. The physician may not stick strictly to the format, but you should be able to at least make out what the patient's subjective complaints were when first seen; what objective findings were found; and what the diagnosis (assessment) was. The other place to speedily find the typed diagnosis from a chiropractor is on the billing pages.
C. Follow-Up
By now you should have a good idea of what is in the curative records, and there may not be any need to dig additional into the handwritten notes. You can begin to rule if you want to hire a curative legal expert, such as a neurologist or orthopedic surgeon, or you may find that you need to subpoena more curative records first.
For example, go back now and pay singular attention to the "patient history" section of the Er and consultation reports. If there is any indication of pre-existing persisting pain or a former accident, for example, there may be more records from other care providers that you will need to subpoena before you can sense your expert or unblemished the Judicial Counsel Form Interrogatory responses. Also, be sure to pay attention to the "current medications" section of the Er or "History and Physical" records. If the outpatient was already on narcotic pain medication, for example, there may be a pre-existing question which you are not aware of.
In the example of carpal tunnel above, you would have found from your "Google" quest that this is a syndrome that frequently comes on slowly over time from repetitive use of the wrist, such as when typing, rather than from a traumatic event. So you would now need to quest the records for complaints of "parasthesias" (unusual sensation such as numbness) in the hands before the incident. You might need to subpoena former records to find out if the carpal tunnel was caused by work and not by the incident.
Before you answer the Form Interrogatories or hire an expert, there is one last source of relatively cheap information that you should not ignore. sense the treating doctor. For example, if you have a plaintiff who had a torn Acl in the knee repaired after a collision; sense the surgeon to confirm the surgeon agrees that the car emergency was the cause of the injury and created the need for surgery. You can practically always set up a short free telephone seminar or maybe one costing only a integrate of hundred dollars.
Although not strictly associated to the records, you should make every exertion to attend the defense curative examination. At the defense curative exam you can personally inspect what tests were beyond doubt performed by the physician and, more importantly, see for yourself how the plaintiff reacts. Check the report report for the results of orthopedic tests that the defense physician claims were performed.
D. Conclusion
I hope this overview helps the next time you are reviewing a stack of apparently disorganized and illegible curative records. always remember that anything you find in the curative records yourself is only part of the picture. Ultimately you are going to need a curative expert who knows the records and can testify to an view on the cause of each injury, the nature and extent of each injury, and the reasonably important past and time to come curative charges associated with the injuries.
How To Read and elucidate healing Records In Personal Injury Cases
