DECODING MEDICAL RECORDS IN MALPRACTICE CASES | DC Metro Area Medical Malpractice Law Blog

One of the key tasks we initially perform when investigating a case involving malpractice or abuse at a health care facility is a thorough review of the medical records. Here are a few basic tips to keep in mind when looking at records:

COMPLETE CHART

The first task is to review the records and try to make sure you have a complete set. Often, the records are incomplete. We check to make sure we have an initial History & Physical, Orders, Physician Progress Notes, Nursing Notes, Laboratory Data, Radiology Reports, Operative Notes, Operative Records/Consent Forms, Pathology, and a Discharge Summary.

Medical Records for pregnant patients are quite different. We have extensive experience with these types of cases as well. In childbirth cases you will also have to review the prenatal records from the mother’s office visits before the delivery. It is key to obtain the Fetal Monitor Strips (FMS) or Fetal Heartrate Strips (FHR) which demonstrate the baby’s heart rate relative to the mother’s contractions. This is often critical in determining if the doctor acted promptly to deliver the child and avoid injury to the child. You will also need the child’s chart and the operative delivery records.

INITIAL HISTORY & PHYSICAL

Doctors are required to write a detailed note within 24 hours of a patient’s admission. This note is often referred to as the “H&P.” This is a good place to start in your review since it usually provides a history of the patient’s present condition and symptoms, past medical and surgical history and any significant labs or imaging results. The note also usually includes a detailed plan for the patient.

ORDERS

Physicians have the responsibility and authority to order medication, labs, imaging and other services that the patient or nursing home residents need. We check these orders to see what medication or services or consults have been ordered for the patient. The orders should have a time and date and should be legible. It should also have some indication that the R.N. acknowledged receipt and review of the order and that it has been carried out. Some special order sheets may also be included like a patient controlled analgesia record (“PCA”) which is utilized if the patient has a pain pump which allows medication to be self-administered at regular intervals.

PROGRESS NOTES

There is another section of the medical record that includes entries by doctors and nurses, and sometimes others like consultants, physical therapists, pharmacists and medical residents. This section often looks like a diary or a log. Most doctors were trained to write their notes in a SOAP format. The first section should detail the “subjective” concerns of the patient. The “objective” section follows and this is where the physician performs a physical examination of the patient and records the findings. The doctor usually goes through each system of the body and records the important findings or any changes. The third section is “assessment” – which is the where the doctor records his or her thoughts about what is going on with the patient after considering the subjective complaints and the findings on physical examination along with any test results or images. The final section is the “plan.” Here, the doctor writes out the plan of action which should address the concerning findings and include a plan consultations by other specialists, medication changes, labs or imaging that is necessary and other follow up.

NURSING NOTES

In some facilities the nurses also write in the progress notes along with the doctors, but in many hospitals the nurses have their own checklists and flow sheets where they record their nursing assessments and interventions from their shift. There may also be other specialized forms for medication administration (MAR) and for treatment (TAR).

In long term care facilities (nursing homes) we check the skin sheet to verify if the patient is being turned and the skin integrity is being checked. *Families are reminded that you must also check your loved one’s skin yourself. It is key not to let any concerning new “hot spots” progress. If you see a red spot or a pressure point that is concerning you need to ask questions and get the staff to act on it right away.

If a patient has a fall or any other abnormal event, the facts and circumstances should be clearly documented in the progress notes along with a plan. In most cases, a fall requires prompt physician assessment.

LABORATORY REPORTS

The laboratory report can also give you clues about what is happening with the patient and what needs to be addressed. A high white blood cell count (WBC) can be a sign of an infection. The lab usually provides the normal range for each value on the report so that you can compare the patient’s value to the normal population. In most labs the patient’s value will be followed by an “H” or an “L” if the value is abnormally HIGH or LOW. For lab values that are critical, or an emergency, the lab also usually includes documentation that the result was called into either the physician or the nurse assigned to the patient and the time of that conversation. It is often the case that you can have the facility print out a laboratory summary report for the patient that shows the results of the lab data over many days, an entire hospital stay or over the course of many hospital stays. This can be quite helpful in terms of tracking trends.

RADIOLOGY REPORTS

Many patients also have x-rays, CT scans, MRIs, mammograms, sonograms or other diagnostic imaging performed as a part of their hospital stay. The written reports from these tests should also be included in the hospital chart. You can often determine the date and time the image was obtained, which physician read the image and also if the image is very concerning, the radiologist often documents that the results were called into the patient’s doctor or nurse directly and the time of such a call. The written reports may also suggest additional follow up testing or imaging that may be required for the patient given the clinical circumstances. You also need to be careful because occasionally there are initial preliminary reports of the results and then final reports. If this is the case, you want to carefully compare the two for any significant differences.

Sometimes imaging is obtained before, during or after surgery while the patient remains in the operating room so it is important to make sure you obtain all of that imaging and those reports as well.

OPERATIVE RECORDS

If the patient has had a surgical procedure, as an in-patient or in a same day setting, there are certain required records that will be present. First, the pre-operative assessments, including anesthesia assessment and the consent form for the procedure. In some circumstances the patient will have had an x-ray, a cardiac clearance or certain blood work performed to make sure it is safe for the surgery. The anesthesia provider will meet with the patient and obtain a history and assess the patient for anesthesia risks. Also, the surgeon will talk to the patient about the surgery and obtain a written consent from the patient.

During the surgery, the healthcare team documents many things. The nursing staff document on records often called “perioperative” records that include safety checklists performed prior to surgery, including patient placement, verification of the surgery to be performed including which side and which surgery and other safety factors. The nursing team keeps track of which surgical instruments are used during the surgery and must account for all instruments at the end of the surgery before the patient is closed to make sure no instruments or sponges are left in the patient. The nurse also documents which nurses are in the operating room and when they leave. At some hospitals the doctor’s entrance and exit are also noted.

The anesthesia providers keep a very detailed log of the patient’s vital signs during surgery, the medication that are given and any response the patient has to medications.

The surgeon does not take notes during the surgery but is required to dictate a detailed operative note following the surgery.

The patient is moved to the post anesthesia care unit (PACU) following most surgeries. This used to be called the recovery room. In most hospitals the patient is monitored by nurses and the anesthesia team in this area for a certain amount of time until the anesthetic wears off and the patient is either ready to leave based on certain discharge criteria or the patient is transferred to the hospital floor if it is a more involved surgery.

PATHOLOGY

If a patient has cultures take, a biopsy or a surgery that involves removal of tissue, the patient should have a pathology report. If the report involves growth results of a culture it can take a few days or several weeks for the final report to be issued. Oftentimes we have to call and obtain those final reports as they may not make it to the final paper version of the hospital record.

DISCHARGE SUMMARY/AUTOPSY RESULTS

Once a patient leaves the hospital, the attending physician is required to dictate a discharge summary. Most hospitals require the discharge summary be completed and signed within 30 days of the date the patient leaves the hospital. This is also true if a patient dies in the hospital. In that case, you will also want to request any autopsy report or findings. There are certain circumstances involving patient deaths where the facility is required to conduct an autopsy based on state law. In other circumstances a physician may ask for an autopsy or a family may request one. Again, certain testing may be done as part of an autopsy and the results may take a few days or have to be sent to a separate lab so make sure you obtain all of the results that accompany the autopsy. In a medical case, we often request the entire autopsy file which may include photographs, tissue blocks and/or pathology slides with special staining.