Emergency room medical record review – vital in personal injury claim settlement
Emergency Room Medical Record Review – Vital
in Personal Injury Claim Settlement
Medical records and medical bills are the most important
evidences when it comes to personal
injury claims. Lawyers involved in
personal injury lawsuits need to evaluate
these valuable evidences to find out
whether a claim is a valid one. Detailed
medical record review involves a
scrupulous analysis of the medical
issues in a claim. Such reviews are
helpful to attorneys in terms of the valuable time and money saved.
In a personal injury case involving a vehicle accident, the
evaluation of medical issues begins with the review of the
emergency room records and the notes made by the rescue squad.
The information the claimant may have filled out in writing or told
an attending healthcare professional after the injury is also
important when reviewing the patient’s medical records. An
attorney with limited knowledge regarding medical terminology
and medical procedures and his/her office staff may be wasting
valuable time if they choose to review the medical records inhouse. Professional medical review service is advisable because
such seasoned reviewers will ensure that lawyers and attorneys are
not surprised in the courtroom or during case settlement
discussions by the sudden emergence of some damaging evidence
in the medical records.
Medical Record Review for Emergency Room Records
In vehicle injury cases, there may be rescue squads involved who
may have taken the patient to the emergency room. Once the
rescue squad and ER records are obtained, reviewers would first
look at the rescue squad records to understand the course of events
before the patient’s admission to the ER. This would provide
valuable data such as the nature of the patient’s injuries, whether
the patient had used a seat belt, and whether an airbag was
deployed which caused some kind of injury to the patient. These
records would also provide details regarding the car and its parts
such as steering wheel, seats and windshield and whether these had
contributed to the injuries acquired by the patient. Experienced
medical record reviewers would also look for data pertaining to the
plaintiff’s activities at the scene of injury, the treatment provided
on the way to the ER such as administration of oxygen, and
whether any photos were taken by the rescue squad.
As regards the emergency room records, the patient’s history and
physical records that may be available will be reviewed for a clear
understanding of the patient’s medical condition. Other important
information a reviewer will look for in ER medical record review
• The person who attended to the patient first such as a triage
nurse, before the patient was admitted to the ER.
• When the patient was admitted to the ER. The important
thing here is whether the admission was on the same day as
the accident or whether it was delayed; and also whether any
reason is indicated for the delay.
• How the patient was brought to the hospital, whether by a
rescue squad or by some other means of transportation.
• If the patient was brought to the ER by a rescue squad, the
records would be studied to find out whether the patient’s
complaints tally with those recorded by the squad.
• Evidence provided by imaging records, and also whether
these are in keeping with the patient’s complaints.
• Whether the X-rays were checked by a radiologist after they
were read by the ER physician.
• Evidence of chronic medical conditions.
• Whether there is any report of loss of consciousness at the
• Details regarding regular medications such as narcotics and
sedatives that may cause drowsiness.
• Evident signs of alcohol consumption and blood alcohol level
(each state may have a specific legal definition of
• Evidence of drug use; it is important to determine whether
the patient was given any narcotics in the ER.
• Attending nurses’ observation notes related to the injury.
• Discharge summary details. Here the reviewer has to clarify
whether any discharge instructions provided were oral or
written and whether the patient signed to the effect that
instructions were provided.
• Any prescriptions given and the type of medications.
What the Professional Touch Is All About
Professionalism matters when reviewing emergency room and
other medical records because an experienced medical reviewer
will not miss even the minutest detail that may escape the scrutiny
of a medically untrained person. For instance, a person
experienced in reviewing medical records would be on the lookout
for objective findings in the emergency room records. These
include findings that are definitive and cannot be manipulated by
the patient. This touch of professionalism is of immense benefit to
attorneys involved in personal injury, workers’ compensation and
other such medical litigation because comprehensive medical
reviews give them a clear understanding of each case. They can
work on a solid foundation of evidence that will facilitate easy
understanding of the plaintiff’s injuries. Accurate information
gathered from the medical records will help attorneys validate or
disprove injury claims.