Emergency Department Medical Records Part 1

Use your legal nurse consulting skills to help attorneys understand emergency department medical records. Here are some of the details in emergency department medical records that affect personal injury cases.

Analyzing emergency department medical records

• Who first saw the patient? Usually a triage nurse will evaluate the patient before the patient is officially checked into the emergency department (ED).
• How did the patient arrive at the ED: by car, squad, or helicopter?
• When did the patient go to the ED in relation to the accident? Was the patient seen in the ED the same day or was the visit delayed?
• If the visit did not occur the same day as the accident, what was the reason provided for the patient’s delay in seeking medical care at the emergency department? Does the record say “Patient instructed to go to ED by his attorney?”

Digging deeper into the emergency department medical records

• What were the patient’s complaints? Were these the same complaints documented by the rescue squad at the accident scene?
• What were the injuries? If the patient was rear-ended, did the emergency department medical records document low back or cervical spine symptoms? (These symptoms may not occur until twenty-four hours or more after the accident.) Were lacerations severe enough to be sutured? What x-rays were taken, and what did they show? If the patient complained of pain in a limb, was the correct limb x-rayed?
• Is there documentation of the use of a seat belt? do the emergency department medical records state the patient was restrained at the time of the accident? Often this fact is changed in subsequent records. At times the patient who is unrestrained at the time of the accident may claim to have been using a seat belt when giving a history of the accident to a treating physician.
• Did the patient have chronic medical conditions? Look for seizure disorder and transient ischemic attacks (potential for raising questions of liability), arthritis (pre-existing condition), deafness (potential for raising questions on liability), hypoglycemia (drop in blood sugar which may result in lowered attention and may contribute to causing an accident), and glaucoma or cataracts (decreased vision may have contributed to the accident, particularly if it occurred after dark).
• What medications did the patient take on a routine basis at the time of the accident? Look for sedatives and narcotics, which may cause drowsiness. Use of narcotics or other pain relievers raise questions about pre-existing conditions. Use of eye drops raise issues concerning visual acuity. A history of treatment with antidepressants may be significant if the patient claims to have developed depression as a result of the accident (as a new condition instead of acknowledging the existence of a pre-existing condition).

Learn more about how to analyze emergency department medical records in part 2.

Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. Learn more great tips about analyzing emergency department medical records, with an emphasis on medical malpractice cases. Invest in a copy of Analyzing Emergency Department Medical Malpractice Cases by Pat Iyer. Get ordering information at this link.