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Medical history documentation – the need for completeness and accuracy


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Medical documentation must be complete to ensure a clear understanding of the actual facts of a case. It will help to distinguish abuse from non-abuse in child abuse and other injury cases.

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Medical history documentation – the need for completeness and accuracy

  1. 1.                                        1­800­670­2809 Medical History Documentation – the Need for Completeness and Accuracy Medical documentation must be complete to ensure a clear understanding of the actual facts of a case. It will help to distinguish abuse from non-abuse in child abuse and other injury cases. Medical records are the best pieces of evidence in any personal injury case. They show the extent of injury, and the treatments received by the claimant. Attorneys representing claimants request for the relevant medical records in order to start building a case. A detailed medical record review would reveal the following things: • The extent of injury • Pre-existing conditions • Dates and periodicity of treatments provided • Whether future treatment would be required • Whether there is chance of future health complications Personal injury lawyers are usually assisted by medical review professionals who have the necessary medical expertise to identify the important facts in the records. When representing a                                        1­800­670­2809
  2. 2.                                        1­800­670­2809 claimant, the lawyers would be looking for facts that support the claim. Insurance companies also employ injury lawyers to represent them when they suspect the legality of a claim. Personal injury lawyers also deal with cases of abuse, such as child abuse and its effect on the child. Abusive Head Trauma and its Aftermath Here is a case that would call for a review of a large number of medical records. In recent news, a Rome man who pleaded guilty ten years ago to violently shaking his newborn baby is expected to decide soon whether he wanted to admit that those injuries caused the girl to die nine years later. Prosecutors believe that the physically disabled nine-year-old girl’s death in 2012 is linked to the above mentioned assault that happened nearly ten years ago. The accused man’s lawyer has asked the Judge two weeks time to review all the medical records of the little girl – medical records that date as far back as 2003. In this case, State law allows the man to be prosecuted for the death of the child irrespective of the fact that he was already previously convicted of assaulting her. The accused was charged last month with second-degree manslaughter. The baby had suffered a traumatic brain injury from being shaken in the year 2003, and died in 2012. Investigators and medical experts took a year to determine that the girl’s death was as a result of the father’s reckless act. Both sides will have to depend on the voluminous medical records available to come to a fair decision.                                        1­800­670­2809
  3. 3.                                        1­800­670­2809 Shaken baby/shaken impact syndrome (or SBS) is abusive head trauma or inflicted traumatic brain injury. This can result from shaking a child, dropping or throwing a child or as a result of direct blows to the head. In the United States, head trauma is the leading cause of death in child abuse cases. Infants are particularly at risk for injury from shaking and most of the victims are below 1 year age. These injuries are seen in children up to 5 years old, although the average age of victims is between 3 and 8 months. Around 60% of victims of shaking injury are male, and the risk is more for children belonging to families that live at or below the poverty level. In cases such as the above, abusive head trauma often lead to permanent damage and in serious cases, children succumb to their injuries. Even if they survive, they may have issues such as hearing loss, developmental delays, impaired intellect, memory and attention deficits, learning and speech difficulties and other problems. Since the signs of problems caused primarily by shaking may not be visible immediately, it is quite difficult to link these issues to a shaking incident that happened many years back. Medical Records and Their Legal Value Investigators in the above mentioned case would be focusing on collecting information regarding the injury. They would conduct interviews with the medical personnel who had attended the child and review the medical records from the healthcare providers. All medical personnel who had contact with the                                        1­800­670­2809
  4. 4.                                        1­800­670­2809 family including doctors, admitting personnel, nurses, emergency medical technicians, ER personnel and ambulance drivers would be contacted for a clear view of the case. Injury lawyers involved in such cases would also work along similar lines. They would need the opinion of all providers and will have to understand the diagnoses and treatments provided. The opinion of the attending physician is of great significance in this regard. Accurate and clear medical chart chronology including that of current medical records as well as those of any prior treatment becomes important to comprehend the various medical terms used and thereby have a clear idea about the exact nature of the injury. Comprehensive and reliable documentation is of utmost importance in injury cases such as child abuse. Details about how, when and where the injury occurred, whether witnesses were present, descriptions of past injuries, and the child’s developmental abilities at the time of injury are all vital. The injury record has legal value because the judicial system uses the medical history as presented in the records as a major factor when judging the credibility of medical witnesses. The physician’s testimony should be in keeping with the medical record details. A 2010 report sponsored by the US Department of Health and Human Services highlights child maltreatment as an important problem in the United States. 3.3 million referrals are there to child protective services across the U.S in 2010, and 60% of these referrals prompted formal investigations. More than 400,                                        1­800­670­2809
  5. 5.                                        1­800­670­2809 000 cases of child maltreatment were proved. 78% of child maltreatment cases were attributed to neglect while 18% were defined as child abuse. The investigations also showed that white children comprised the largest group of maltreated children. Posted by MOS Medical Record Review Company                                        1­800­670­2809