Getting Medical Records After An AccidentGetting medical records after an accident in Florida is an essential part of handling the injury claim. Medical records provide a view of the pain and suffering endured by the patient during treatment. They are vital components in building an understanding of medical treatment and pain and suffering management. In this article I will discuss obtaining medical records after an accident, assuring completeness of the medical records and some basic information on organizing and analyzing the medical records.

Obtaining Medical Records

The assessment of pain and suffering sustained in any Florida personal injury case, must be done in the initial evaluation of a potential new case.  The first step in reviewing a potential client’s personal injury case is obtaining medical records.

Obtaining medical records can be tricky. Sometimes even Florida injury attorneys face resistance or delays in obtaining records. A helpful strategy is to send a records request in the form of a letter that contains the time frame within which the entity should respond to your records request (within 30 days).  You’ll also want to include a signed and notarized copy of a HIPAA authorization. Medical records will not be provided without a proper HIPPA release.

Once a medical records request has been sent, follow-up to ensure the request was received by the right person or department. This should be done about 10-days after the request was sent. Most entities are now subcontracting patients’ requests for medical records.  You don’t want to discover a month later that your medical records request was not received because it was sent to the wrong place.

Assuring Complete Medical Records

The goal should be to obtain complete medical records as fast as possible. Completely records are defined as full, certified copies of medical records from institutions (hospitals, rehabilitation facilities, and nursing homes) and complete physician office records.

When medical records are received make a copy of the records without changing the order of the pages, and then store this copy in a safe place. I recommend making a scanned copy, and then save on a secure, cloud-based network like DropBox. This way you’ll have both a hard copy and an electronic copy. The electronic copy can be accessed virtually anywhere in the world.  Note: Before you upload your medical records be sure the network is secure.

It is also recommended that you keep the envelop in which the medial records came. If a question of tampering with medical records is raised, it is helpful to be able to verify the date on which the set of records was mailed (and received). This set may be compared with future sets obtained during litigation.

After you’ve received (and copied) the medical records the next step is assuring you have complete records.  Although a copy of a certified medical record should compared by the medical records custodian with the original, it is common for pages to be missing.  This often happens because of user error during copying. However, with new technology and electronic medical records, I’ve noticed this is becoming less of a problem.  Still, you need to make sure you have a complete copy of the medical records.

The best way to determine if the medical records are complete is to organize the medical record. This will help you locate any missing sections of the record.  Pages in the medical record are often arranged in reverse chronological order. In other words, the most recent records are on top. I always organize the medical records file so it reads like a story. The initial records are first, followed but future medical treatment. To me chronological order is the best way to get a full understanding of the medical treatment. When the records are organized correctly, you can use Bates stamping software to label the page numbers accordingly.

When sending your medical records to a doctor or attorney for review, you’ll want to be sure the records are organized and correctly numbered prior to being scanned or copied. The copies should be clear and easy-to-read. Trying to locate information in a disorganized set of medical records will only lead to frustration.

Analyzing and Organizing Medical Records

There are many different types of medical records, all of which are important.  Below you’ll find an overview of a few of the different types of hospital records and I’ll discuss their importance to your accident claim.  Please be aware that there are many other types of records you may need to obtain, but here are just few.

Emergency Room Records

Emergency department records are often detailed sources of information regarding your condition upon arrival to the hospital.  Emergency room records should be reviewed to determine things like: your level of consciousness, symptoms such as pain and discomfort, reactions to treatment, diagnostic tests and treatment rendered, and pain medication administered.

Hospital Discharge Summary

The thoroughness of the hospital discharge summary can range from bare-bones to complete. It is often the responsibility of a resident or intern to complete discharge summaries in a teaching hospital. If accurate and complete, the discharge summary is usually a good place to begin to understand the major problems you may have experienced during the admission.

Physician Orders

Physician orders may include orders for diagnostic testing and treatments which inflict pain, and medication that relieve pain and suffering. Here, you can often find “gold” in building your accident case.  What I mean is because pain is so subjective, insurance adjusters and defense attorneys love to argue that your pain is not that bad or that you are “exaggerating.”  That’s a tough argument to make when your doctor ordered painful treatments like a catheter, a debridement, wet to dry dressings, suctioning, insertion of chest tubes, and so on.  Additionally, if you were given strong pain medications to receive pain, this would further prove the legitimacy of your injuries.

Progress Notes

Physician progress notes are generated by various physicians that have interacted with you during hospital admission. From a resident to the most seasoned doctor on staff, documentation about your condition can be found in the physician’s progress notes. Essentially, these notes provide a quick overview of your status

Physician’s progress notes may also include terms that describe your pain level. You may have been asked to describe your pain on a scale of 0 to 10. This is another trick defense attorneys love to use; they’ll quiz you at your deposition months down the road and ask what you’re pain level was on the day of your accident.  If the numbers don’t match up, they will claim you’re being untruthful, attacking the legitimacy of your claim. This is why I always provide my clients with a summary of their medical treatment to use as a guide during depositions.  After all, depositions in accident cases are not memory tests.

Nurses’ Documentation

Nursing documentation typically consists of several sections.  First, the nursing admission assessment usually consists of information collected by the nurse on admission to the hospital.  It is usually a systematic history and examination of the body systems and identification of the chief complaints.  Admission assessments questions usually include questions about the presence of pain and how the patient typically attempts to relieve it. The patient may also be asked to rate the intensity of pain, the location, quality, onset, duration, and the alleviating and/or aggravating factors. Information is usually asked about the pain management history which includes a description of what medications and other interventions are effective, how the pain affects that patient’s daily life, and the patient’s pain goal.

Again, nurses’ notes will typically contain documentation of the patient’s quantification of pain.  The most common scale in use is the numeric pain intensity scale.  Using this scale, nurses’ notes and physician progress notes will often state the patient’s pain score in terms of a point between 0 and 10.  For example, the record may have an entry such as “patient reports pain is a 6 out of 10.” A number of studies have shown that a pain rating at 4 or more on a 0 to 10 pain rating scale interferes significantly with daily function.  A pain rating this high indicates the need to revise pain treatment with higher doses of medication, or other comfort measures.

Surgery Reports

Surgery reports usually consist of consent forms, pre-op evaluations, comprehensive report of operation, anesthesia record, operating room nurse notes, post-op and recovery room records, and surgical pathology report.

The surgical report may describe complications that occurred during surgery, which would impact pain and suffering.  The anesthesia record is also helpful in determining the length of surgery, which is important when long, involved surgery takes place.  Also, review of the record unit records for evidence of complaints of pain and pain medication administration and other medications administered for systems.

X-rays

Hospital records usually contain diagnostic test results.  It is common to group these two categories: radiology/scans and laboratory tests.  You’ll want to review the radiology section for frequency of testing and whether the tests were done bedside or in the radiology department.  Portable x-rays are usually done when the patient is too injured to be moved to the department for the study.

For More Information

For more information about obtaining, organizing, and evaluating medical records for a Florida personal injury case please visit our blog and please don’t forget to subscribe to our YouTube channel!

The Longo Firm, P.A.
Micah J. Longo
12555 Orange Drive, Ste. 233
Davie, FL 33330
Tel: (954) 862-3608
mlongo@longofirm.com