Medical Records: Where to Start?

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Courtesy of Godoy Medical Forensics

If you’re looking for the “story” of how the patient entered the hospital and what happened while he or she was there, go to the Discharge Summary (caution: This is different than the Discharge Instructions, which are essentially worthless unless you practice medical malpractice). The Discharge Summary is a synopsis of the major events in the time that the patient was in the hospital. It will include surgeries, procedures, complications (i.e. infections, organ failure, seizures) and anything else the doctor sees as an important event during the course of the treatment. It will usually be several pages long and will include the admission date and the discharge date at the top, and the discharge diagnoses at the end.

Many doctors will include a complete a review of systems—meaning they go through each bodily system (like the cardiac or neurological system) and discuss any abnormal findings and treatment given. What I recommend is to look at the narrative at the top of the page, which is the “story” of the patient’s care. After that, it just starts getting too technical for most laypersons.

Then skip to the bottom and look at the discharge diagnoses and the plan. The “discharge diagnoses” are the diagnoses that the patient is still suffering from and the “plan” gives the reader an idea of the status of the patient upon discharge: did he/she go home or to a facility for further care and rehabilitation? This is important because it gives you an idea of how functional this patient will be and how long it will take for them to maximally recover. Obviously, someone that is discharged home is more likely to be functional with the activities of daily living (ADLs)—brushing teeth, bathing, cooking, etc.—than someone that goes to a long-term rehabilitation center. Just because someone gets discharged to another facility doesn’t mean they won’t regain functionality in the ADLs; it just means it might take a bit longer to get back to normal.

If you’re looking for a list of injuries, as you commonly are in criminal law, you will look at the emergency department (ED or ER) reports and/or the ambulance reports.

Ambulance/Fire

The vast majority of the time, I have to request that the ambulance and/or fire records be subpoenaed. This is a great source of information! A lot can change from the scene to the ER and the paramedics will document that. And the best part is they have a very concise narrative that tells you exactly what they did and saw. Sometimes, I will catch facts in the paramedic’s report that isn’t documented anywhere else. Was the patient found face-up (supine) or face-down (prone)? A timeline of events is critical in a case involving a seizure. You have to remember that the paramedics are usually the first medical professionals to set eyes on the patient. Having to rely on the police officers and witnesses to tell me what the patient looked like at the scene is not ideal. Plus, the paramedic’s narrative is not usually overly technical and is written much like a story. This is a great place to start your review on any criminal case.

Emergency Department

Ideally, there will be a typed summary from the emergency room physician, but it is often hard to read because it’s mixed up with vital signs, orders (see the “note of caution” below) and procedures, or it simply doesn’t exist. ED staff tends to keep their documentation to a bare minimum. So, in ER reports look for the discharge diagnoses. Even if they are admitted to the hospital, there will be a discharge diagnosis because the ER is considered an outpatient service, so they are “discharged” from the ER and then admitted to the hospital. The discharge diagnosis is usually located on the bottom of the doctor’s notes–usually labeled “Doctor’s Progress Notes,” “History and Physical,” or sometimes “Emergency Physician Record.” Another good source for a list of injuries is the triage note from the ER. This note is written by the first nurse to see the patient, so it will be the first impression of how the patient arrived in the ER. This will not include any diagnoses that require procedures (like CT Scans), but it will include the patient’s mental status, their vital signs and the overall status.

Complications and Procedures

For more information on the hospital course, other documents to look for include:

  • Operative reports: These are generated if the patient undergoes any surgeries, and a separate report will be generated for each operation. Look at the pre and post-procedure diagnosis.
  • Radiological reports: Look at the “impressions.” Again, there will be one report for each and every imaging study done. For example, if an x-ray was taken of a hand, and one of a wrist, there will be one report for the hand, and another one for the wrist.
  • Specialty-specific consultations (i.e. neurology, ophthalmology, etc.): These are typically written in “SOAP” format (S=Subjective, O=Objective, A=Assessment, and P=Plan). Most often it is the assessment that will reveal the general impression of the doctor writing the note.

One note of caution with computer-generated records: make sure you know what you’re looking at before you jump to any conclusions. This might seem like an obvious tip, but oftentimes, an untrained observer will look at something and think it was a medication that was given and then, after a little more review, determine that it’s simply standing orders for the nurses. Standing orders exist so that the nurses don’t have to call the doctor every time the patient has expected pain, or to tell nurses when they should call the doctor. The following examples show how confusing it can be:

  • “Morphine 4mg IV Q4º PRN pain” – in translation, this is an order that says “You can give the patient 4mg of Morphine as often as every 4 hours, when he asks for it, through his intravenous line.”
  • “Increase O2 to 6lpm for sats <95%, notify MD for sats <90%” – this is an order from the doctor that says “IF his oxygen saturation goes below 95%, you can up his oxygen to 6 liters; if his oxygen saturation drops below 90%, I want you to call me” “If” is the key word here – it means the orders are anticipatory, not reactive.

So you can see how these Standing Orders may appear, to the untrained eye, like the patient had frequent dosing of narcotics and his oxygen saturations were low and in truth none of that occurred. I highly recommend review by a medical expert if you are looking for information that is this specific.

 

 

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