READING MEDICAL RECORDS IN A GREENSBORO CAR CRASH

There are two prongs to every Greensboro personal injury case. First, there is liability, meaning fault generally. Who caused the incident, how did it occur, what happened, when did it happen, and where did it happen.

Secondly, there is an injury or injuries. Surprisingly, medical records will address both questions. Reading and understanding the medical records is a MUST!

Approach the medicals records with a curious mind, and understand that you are reading for information. You are a detective, seeking facts and information. Understand that the information you have been provided by your client is subjective, meaning that the client has related information from their perception. In most cases, you do not have all the facts. Clients oftentime misunderstand their condition, doctor’s orders, and the importance of treatment. Most do not comprehend the significance of the injury. Thus, approach the medical records with an open mind.

AMBULANCE:

The first medical record to look for is the report from the ambulance run. EMS workers complete a “run” report. In that report, the EMS records what they observed upon arrival at the scene, the patient’s condition(s), what services were performed, how the patient responded, if drugs were administered, and if appliances were used. Vitals will be recorded. Observations of behavior will be recorded. Information provided by witnesses or investigating officers may also be recorded.

Most of the time, law offices do not receive the run report. In serious accidents, we will want to request it. The “run” report will also include the facility the patient was transported to. Usually, the client will provide the facility information.

Most of the time, we will only receive the bill from the ambulance service. The important information on the bill is two-fold. One, the amount of the bill. Second, the transport information. Transport information may include mileage or excess mileage. This information needs to be reviewed to ensure that the patient/client is not being overcharged.

HOSPITAL EMERGENCY ROOM:

In this article, we will look at a typical Greensboro Car Accident emergency room record from Moses Cone. Below is a list of information contained in ER records.

1. Time of arrival
2. How the patient arrived
3. Who arrived with the patient
4. Where the patient was taken
5. Who the nurse(s) is/are
6. Who the attending is. The “attending” is the professional providing medical treatment. In many instances, the attending will be a PA. Toward the end of the record, you will see the name of the physician who signed off on the PA’s services.
7. What happened to the patient. This information may be provided by the patient, an EMS worker, the family/friend who arrived with the patient, or the investigating officer.

NOTE: It is important to know who provides the information. Also, this section of the record gives the “factual” information as it is provided to the medical team.

8. Insurance is also recorded. This tells you how the facility will be filing for payment.
9. History of medical conditions, medications the patient is on, surgeries, and social information is recorded. This information is important because it provides pre-existing information.
10. Subjective information: includes the patient complaints as he/she relates them to the medical staff.
11. Objective information: includes what the medical provider finds when an examination is conducted. The objective information will be in the “EXAM” section of all systems. Systems include the parts of the body examined. Tests ordered by the attending is objective. The tests will be listed as well as the test results.

NOTE: always look for consistency between the subjective and objective information.

12. Treatment will follow usually after exam and tests. This tells you what the attending did to the patient. You will be able to discern if pain medications were administered, IVs, patient’s response, if a device was applied, etc.
13. Discharge information will be at the end of the record. Discharge includes any medication prescribed and the instructions given to the patient when they leave the hospital. Referrals to specialists will be noted. Follow-up care instructions are important to note. From the discharge, you will know what medications were administered, which medications were disbursed, and what prescriptions were provided.

NOTE: a familiarity of pain medications and muscle relaxers is helpful.

Look up the meds if you are not familiar with them.

14. Diagnosis will be listed. This is very important information, and it is very important to understand the diagnosis. The diagnosis tells you what part(s) of the body is injured, how severely, and the medical code. You MUST understand the diagnosis.

After you have read the ER records, you will know the injury and what to look for next. Follow-up care information is then your roadmap. You will need to investigate to determine if the client followed the doctor’s discharge plan.

Admissions records are complex, and we will address those later. For now, know that admissions records are voluminous, provide a day-to-day description of everything that happens with the patient, all testing, drugs administered, comments on patient’s visitors, level of pain, and so forth. There are many parts to the admissions records.

Numerous abbreviations are used by medical personnel. I am providing you with a couple of lists of same. The “Bible” on abbreviations is Tabor’s Medical Dictionary. When in doubt, you can search it on the web. Many firms have a Tabor’s in the library. You may note a variation of abbreviations in family practice records, but for the most part, the abbreviations are standard across the medical community, regardless of location, and from state to state. Thus, reading out of state records will not be a problem.

Urgent care facility records will resemble ER records, depending on the facility. You approach doctors’ records using the same thought process. Doctor records are much less voluminous, but contain the same breakdown of information. The first visit will contain more information than subsequent records.

With specialists, such as orthopedics, you will frequently see that the doctor’s PA saw the patient, and the doctor reviewed the visit. Again, note the diagnosis, tests, and treatment plan. Also, look for referrals to physical therapy, devises, and referrals to other specialists.

The diagnosis drives the treatment plan. YOU MUST UNDERSTAND THE DIAGNOSIS and treatment plan. And the parts of the body injured. You build your medical knowledge base by understanding and retaining the medical information. The best way to do this is to understand the anatomy of the human body. The web is a great resource.  It is important to know the difference between contusions, bruises, abrasions, fractures and dislocations. Equally important is to understand the function of the body part.

If you do not understand a body part, its function, the diagnosis, or the descriptions, look them up. Reliable sites are the CDC, Mayo Clinic, WebMD, numerous special sites such as spine centers, Lexis/Nexis, and medical dictionaries. Academic sources are always best, but you may not have access to them. Medical school libraries are wonderful.

Attached to this lesson are: (1) list of abbreviations; (2) Medical Evidence in Litigation article; and (3) Medical Records Analysis article. Note any questions you have when reading the articles and we will discuss. The articles are advanced, so do not fret if they do not resonant with you at this point in time as they will eventually.

MEDICAL BILLING FROM ER:

Overall, you will have three bills generated by an ER visit. You will have the facility bill, the physician billing, and billing from tests sources. For example, using Moses Cone ER, you will have a Cone Health bill for the ER. You will have a Wake Forest University Health Science bill for the ER physician and if x-rays were taken, you will have a bill from Greensboro Radiology. Itemized bills are best as they contain a list of services and the medical billing code.

When you encounter a facility that is new to you, call the facility billing department and ask how the billing is broken down and who the providers are. This will give you a list of who you need to request records from.

Billing records provide the service provided, the amount of the bill, the unit administered, the billing code and identify the provider. Billing records reflect if insurance was filed, what insurance, how much was paid, if any adjustments were made, and the balance owed. Correct billing information is absolute. It drives the total bills, the liens and the 414 number. You must have COMPLETE billing information, and in the correct format.

MENTAL HEALTH RECORDS: 

Mental health records include the records of mental health facilities, addiction facilities, psychologist’s records and psychiatrist’s records. These records can be tricky to obtain, to read, and to understand. Such providers are very cautious about releasing information on their patients. You need to handle these providers with kid gloves. Know what you are looking for.   Know that these providers generally have 2 sets of records. They record their notes typically by hand during sessions. Then they produce a “record” for release, if necessary, for the “official” patient file. The notes are generally non-telling, depending on why the patient is being treated and for what condition. Be alert when reading mental health records. An insight to the patient, the patient’s attitude toward the complaints and treatment, their relationships, and their daily activities will be revealed. This type information is very helpful in litigation.

MEDICAL AUTHORIZATIONS: 

A medical authorization must be provided to a provider for the release of records. NO exceptions. The authorization needs to contain the complete name of the patient, the patient’s date of birth, and the patient’s Social Security Number. The authorization needs to identify the records requested, the time frame, and who the records are to be released to, as well as why the records are needed. It is not unusual for a provider to request a specific authorization if the attorney or staff person needs to meet with the doctor.

Typically, in a new case, we only request the records from the date of accident to the present. In litigation, we will need pre-accident records for a specific period of time, typically 5 or 10 years. Do not expect to receive the records using an authorization that says from the accident to the present. It will be rejected.

Authorizations for a minor’s records needs to be signed by the legal guardian which is generally the parent. In some instances, a legal guardian will be appointed or approved by the court. In that instance, you will want the legal guardian to sign the authorizations.

Military records can be challenging to obtain. Prison medical records may be challenging as well. Social Security records are difficult to obtain and, like military records, can take a very long time to receive. Specific authorizations may be needed. Look up the process and use forms from these entities sites.

Contact our Greensboro Personal Injury Lawyers today if you or someone you know has lost a loved one as a result of someone else’s negligence.