Emergency Department Medical Records Part 2

Legal nurse consultants play a vital role in helping attorneys understand medical records. Here are some of the things you may find in emergency department medical records. Read part 1 for more tips about emergency department medical records.

What to look for in emergency department medical records

• Was there a positive alcohol smell noted? This may be written as “+ETOH” or “AOB” (alcohol on breath).
• Was a blood alcohol level (BAL) drawn? Know the legal definition of intoxication in the state where the accident occurred.
• Was a drug screen done? If the patient’s blood tested positive for drugs, look at the rescue squad and ED records to determine if narcotics were given. If the patient was treated with narcotics after the accident, check the time the drug screen blood test was drawn. This will enable you to determine if the blood was drawn before or after narcotics were given.
• What was the patient’s level of consciousness (LOC)? Did the patient report a loss of consciousness? What was the patient’s LOC in the ED? A patient described in emergency department medical records as A&Ox3 (“alert and oriented times three”) knew who she was, where she was and the date. A&Ox4 means all of the above, plus the patient remembered recent events leading up to the ED visit. A&Ox4 is less commonly used than A&Ox3.
• What was the Glasgow Coma score? A score of 15 is the highest possible score. A patient can be dead and have a score of 3.
• What did nurses observe about the patient? What symptoms did the patient experience while in the ED? Was the patient’s behavior consistent with the injuries, or did the nurse document symptoms in the emergency department medical records that would cast doubt on the seriousness of the injuries?

Treatment documented in emergency department medical records

• Were the appropriate x-rays taken based on the patient’s complaints?
• Were x-rays read by the radiologist or only by the ED doctor initially? All ED x-rays must be “over read” by a radiologist later.
• Did the patient receive discharge instructions? Were the discharge instructions written or oral? Did the patient sign that instructions were given?
• Was the patient instructed to seek care from the PMD (primary medical doctor)? Was this done?
• Were prescriptions given to the patient at discharge? If so, what type of medications were prescribed?

Emergency department medical records carry critical information about a patient’s condition and treatment.
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.