The way to Read and Interpret Health Records In Personal Injury Conditions


Congratulations, you now have a pile of medical records nine inches high that you often subpoenaed or your client given! What now? The purpose of this article is just to save the personal injury attorney and anxiety, and with any luck, help you to dig out the key details.

When you are confronted with virtually any task, it helps to 1st have a clear idea of what the objective is, and then perform from the largest part of the activity down to the finer elements. To begin, and even before you get the medical records, it will be many helpful to first have the customer complete a medical questionnaire, so you have a good idea of exactly what records you will need to request.


Once you obtain the records, the initial task is to look at the EMERGENCY ROOM “History and Physical” data, if there are any, after which to search your stack associated with records for any typewritten reviews. Ignore all handwritten information for now. For example, “Discharge Summaries” and “Consult Reports” tend to be invaluable because they quickly sum up the case and point out for you personally where you will need to look following. Be aware that a “discharge summary” may simply refer to an individual being “discharged’ from one model in the hospital, such as the er (ER) or intensive attention unit (ICU), and placed inside floor care or some various other units within the same medical. So there may be more than one “discharge summary for the same patient.

You may now want to see if there are generally any “objective” findings from the ER records or talk to reports. “Objective” can mean various things to different medical experts, but essentially “objective” refers to findings that are not under the voluntary effects of the patient. For example, an x-ray of a fracture is an ‘objective” finding since it will show a real picture of the fracture.

Much less obviously “objective” is an x-ray of the neck that displays a “loss of cervical lordosis” or a “straightening from the cervical curve. ” Typically the cervical spinal column in the neck and throat has a natural curve, plus a loss of this curve may well show that the neck ended up going into muscle spasm thereby causing the neck and throat to involuntarily straighten.

“Spasm” is the involuntary tightening involving muscles and is frequently linked to strain/sprain-type injuries along with pain. Healthcare practitioners, for example, chiropractors and physically trained counselors, are trained to feel muscle mass spasms when they examine an individual. In particular, if you see a mention of asymmetric spasm, this may be a more reliably “objective” finding. For example, try flexing the muscles of just one part of the back of your neck and throat, and you will realize just how challenging it would be to fabricate this sort of finding.

You should now take a look at the records for whichever radiology reports are available. The good news is, these are almost always typewritten and to read. Look for keywords for instance “acute” which indicate how the injury happened during the car wreck. When looking at a spinal CT or MRI scan statement, look for terms that reveal that the nerves are pinched, such as with an “impingement, inch or that something is massaging up against the nerves because when something is “effaced. inch Disc bulges or protrusions are obvious, but also search for less obvious things, for example, an “annular fissure” or perhaps a “torn annulus. ” An easy annular tear may not appear to be much, but this rip in the spinal disc can be very painful and very difficult to deal with. A finding of an annular tear is something to deliver to your neurology expert for any further opinion.

Much less dependable will be the intake notes regarding how the incident happened. For any vehicle collision, the doctor should know the patient’s initial indicators during the crash, but will not possibly be concerned with who was at fault. It can be still worthwhile to look for inside intake records, particularly if there isn’t any police report, to at least find the plaintiff’s recollection of functions close to the time of the unpleasant incident. However, be forewarned of the fact that caregivers who do girl care will frequently just price the intake notes, in conjunction with any inaccuracies, when starting point their own chart notes.

Hunt for things that may require follow-up health care. For example, “ORIF” is simply lingo for “open reduction interior fixation” surgery to repair any broken bone using operative screws. So on that occasion, you would continue to search the particular typewritten records to see if there exists anything about how long the solid (if any) was in the spot; if a course of physical therapy has been started after the cast has been removed; and if there were virtually any adverse reactions to the surgical anchoring screws. It would not be too abnormal to have to remove some of the operative hardware if it was producing inflammation or some other almost problem. There should be some clue of such inflammation inside follow-up reports if it persisted.

While reading typewritten or even handwritten notes, hunt for abbreviations that may easily point out what is being referred to. For instance, “C/O” in the “History in addition to Physical” notes is short for “complaining of. micron What follows will immediately wrap up the patient’s complaints since they existed at that time. Similarly, quite a few “2” with what looks like a level symbol after it represents “secondary to. ” Put simply, for example, neck pain “secondary to” a car accident simply ensures that the onset of neck soreness happened after a car accident.

Additional abbreviations refer to frequency, including when an ordered treatment is to be given. QID suggests four times a day; PERIOD means three times a day; PUT MONEY means twice daily, in addition to PRN means that the medicine, such as pain medicine, shall be taken as often as meant for pain control. “PO” ensures that the medication is to be offered orally. A small “c” using a line over it means “with” and a small “s” using a line over it means “without. ” Remember that medical information uses scientific terminology, thus a small triangle means “change, ” and not “defendant, inches as it would in-laws.

Ordinarily, you can just disregard the reams of laboratory records that will inevitably accompany a new patient’s records. However, in the event for some reason a particular lab valuation, such as blood sugar (glucose), is significant to the case, there will commonly be a guideline as to what “normal” values should be. Find these kinds of normal values at the top or perhaps bottom of the page, or perhaps sometimes on a separate webpage, and then just go back and show what the actual assessed values were.

Be aware, still that the lab values seen in an autopsy report are generally not exactly like the medical report of a living person. Liquor, for example, ferments in the body immediately after death. So a blood vessel’s alcohol level taken with an autopsy after death doesn’t necessarily correspond with the blood vessel’s alcohol as it existed for the duration of death. You will almost certainly consult a pathologist for an expert opinion on the write-up mortem toxicology.

If you talk about an unfamiliar medication or problem while reviewing the information, do not be afraid to “Google” it. We have available to people wonderful and instant access to a whole range of medical understanding if we simply take a few minutes to analyze it on the internet. Looking up an ailment, such as “carpal tunnel” may well not make you an instant expert, however, you will at least know if it can be caused by trauma.


At some point perhaps you are going to need to deal with the written-by-hand notes. For example, there may be not any typewritten discharge summaries as well as intake reports, and you are easily going to have to go through the files looking for documents entitled so. Some practitioners, such as chiropractors, frequently have handwritten paperwork only, so you will have to aim to wade through the usually unintelligible handwriting. Fortunately, even the following there should be a couple of helpful parts in the file for you to consider.

The first is the “pain plans, ” which is a schematic format of a body with coded areas of pain. This is usually completed by the patient, and is a significant record, in the patient’s individual “words, ” of exactly what the patient was complaining involving at the time.

The other helpful written-by-hand records will be labeled “SOAP” notes. This is just a consistent “Subjective-Objective-Assessment-Plan” format. The doctor might not stick strictly to the file format, but you should be able to at least see what the patient’s subjective issues were when first observed; what objective findings had been found; and what the analysis (assessment) was. The other spot to quickly find the typed analysis from a chiropractor is within the billing pages.


By now you should have a good idea associated with what is in the medical data, and there may not be any kind of need to dig further into the handwritten notes. You can begin to make the decision if you want to hire a healthcare legal expert, such as a specialist or orthopedic surgeon, otherwise, you may find that you need to subpoena far more medical records first.

For instance, go back now and shell out particular attention to the “patient history” section of the SER and consultation reports. If you find any indication of pre-existing chronic pain or a past accident, for example, there may be far more records from other care guru services that you will need to subpoena simply using contact your expert or finish the Judicial Counsel Application form Interrogatory responses. Also, be sure you pay attention to the “current medications” part of the ER or “History and Physical” records. When the patient was already on narcotic pain medication, for example, there might be a pre-existing problem that you are not aware of.

In the example of the carpal tunnel above, you would have discovered from your “Google” search this is a syndrome that regularly comes on slowly over time through repetitive use of the wrist, for example when typing, rather than from the traumatic event. So you might now need to search the actual records for complaints associated with “paresthesias” (unusual sensation for example numbness) in the hands prior to the incident. You might need to subpoena previous records to find out in case the carpal tunnel was a result of work and not by the episode.

Before you answer the Form Interrogatories or hire an expert, there may be one last source of reasonably cheap information that you should not necessarily ignore. Contact the managing doctor. For example, if you have some sort of plaintiff who had a divided ACL in the knee mended after a collision; contact typically the surgeon to confirm the operating doctor agrees that the car accident caused the injury and came up with the need for surgery. You can definitely set up a short free mobile phone conference or perhaps one charging only a couple of hundred us dollars.

Although not strictly related to the particular records, you should make every single attempt to attend the security medical examination. At the security medical examination, you can privately observe what tests have been actually performed by the medical doctor and, more importantly, see by yourself how the plaintiff reacts. What is the narrative report for the outcomes of orthopedic tests that the security doctor claims were conducted?


I hope that overview helps the next time that you are reviewing a stack of apparently cluttered and illegible medical files. Always remember that whatever you come across in the medical records yourself is only part of the picture. Finally, you are going to need a medical skill who knows the records and may also testify to an opinion for the cause of each injury, the character and extent of each harm, and the reasonably necessary recent and future medical rates associated with the injuries.

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