Records and are the heart and soul of all cases involving medical suits. These can include facilities, specialties, and ancillary records. They can be electronic, dictated or handwritten. They can be few or mountainous. Truly, there is no such thing as an average amount of records.
And regardless of the type of case, the records tell the story. The following discussion highlights several key areas that should be examined carefully in all records as they provide the details of what happened or what did not happen with the patient during their care.
History and Physical (H&P) or Initial Evaluation: The H&P is important to evaluate the chief complaint (subjective), current signs and symptoms, co-morbidities, history, current medications, exam (objective) findings, original impressions or diagnoses, and recommended treatments. Did the objective findings support or correlate with the subjective complaints? Were the treatment recommendations appropriate? Did the co-morbidities have any effect on the recommendations? Was treatment delayed or unable to be completed? Was there a history of the current complaints? If so, how long ago? Did it resolve completely and when was the last treatment? How frequent were follow-up visits? Were there gaps in treatment?
Physician orders provide direction to all disciplines involved in the care of the patient. Were the orders clear? Were they appropriate and related to the diagnosis? Were the orders carried out? Were they implemented within a reasonable time frame? Was there a delay in treatment? Were referrals made to other specialists? Were those records obtained? Was the diagnoses and subsequent treatment related?
These reports provide the story of care and create a timeline of the patient’s condition from the beginning. Was the patient improving? Were there objective findings confirming progress was being made? What additional testing and/ or treatment was recommended? Was it appropriate? What were the results? Did new complaints arise days/weeks/months later? What additional testing and/or treatment was ordered for the new complaints? What were the findings of this additional testing or treatment? Were there inconsistencies or late entries?
These records provide the name, dose, frequency and route of medications that are being prescribed. Were the medications related and correct? Was the dose appropriate? Was the frequency within the recommended guidelines? Were medications FDA approved for the diagnosis or were they off-label? Were there side effects? Were generic or brand name medications being used? Were medication interactions checked? If so, what were they? Did medication interactions delay recovery time? Did they add or require additional treatment?
These reports provide information about the patient’s current status. Were the lab values within the normal range? How frequent are labs being drawn? Were there any unexpected findings that point to some underlying condition that has not been diagnosed? Were the correct labs drawn (for example if Coumadin was prescribed were PT/INR being drawn and if so how oft en)? If the patient was taking narcotics were urine drug screens being completed and how often?
These reports are important in confirming diagnoses. What were the findings? Were they degenerative in nature or acute? Were there any unexpected findings? Were the unexpected findings related to the diagnoses? What was the result of the unexpected findings? Was the test completed by the appropriate specialist? Was the test result interpreted by the appropriate specialist?
These records provide ongoing insight into the progress of recovery. Were treatment recommendations appropriate and prescriptions obtained? Was there documentation of continued improvement? Did the exam show measurable, objective evidence of improvement? Was there a start/stop time documented for all treatment? What modalities were implemented? Were they appropriate? Were there gaps in treatment?
Reviewing medical records can be daunting and a little bit intimidating. And trying to understand what happened, when it happened, and the effect is challenging.
Knowing what to look for and where to look is the key to understanding what happened while highlighting both strengths and weaknesses throughout the case. Janet Bailey Parker