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Interpreting Medical Records

By Armando Leone, Jr.

Before an attorney can delve into a hospital chart to understand the nature of and reason for your client’s injuries, the records need to be organized in chronological order by type of document. Commercial medical dividers are available for purchase, but the following general organizational categories are useful; admission documents, discharge documents, provider notes (physician and nurse), consultation notes, orders (including medication sheets) , reports and lab data. Some medical records, although made in the hospital, are not regularly included with the hospital chart and need to be requested separately. These include Ambulance Run Sheets, Outpatient Clinic Records, Holier Monitor Strips, Fetal Monitor Strips, Autopsy Reports and Incident Reports. By understanding the different types of available information, one can selectively review the records and efficiently answer questions about your client’s case. OBTAINING AN OVERVIEW The documents which provide the best overview of the injuries and damages in a case are the admission and discharge documents. The Admission Intake Form, which is filled in by a clerk in either the emergency room or the admitting office, contains basic vital information about the patient, such as date and time of treatment, the admitting doctor, the reason for the hospitalization, and often, if through the emergency room, the physician’s notations concerning the history and examination of the patient. The Discharge Note provides information about the patient’s admitting diagnoses with a discussion of the relevant clinical history, secondary diagnoses, relevant lab results, the patient’s course of treatment in the hospital and condition upon discharge. Lastly, the Admission Note describes the clinical situation when the patient presented to the hospital, along with the initial diagnostic impressions and planned work-up. These overview documents quickly give one an idea of the extent of damages from the injury at issue, as well as identifying relevant pre-existing diseases which may detract from the value of a case. The Discharge Summary, in particular, provides a concise clinical summary of the patient’s presenting problems and hospital course, which is useful for attorneys and paralegals who prepare written medical summaries for expert or insurance carrier review. It is important to understand the format physicians use to record clinical information, in order to extract the necessary information. The main elements of any note are the history, the physical exam, the lab results and the diagnostic plan.

Anatomy of a Note

A physician takes a history and performs a physical examination of the patient which is sufficient to address the issues presented by the patient. This can be as broad or as narrow as required – the most comprehensive note being for an admission and the least comprehensive, but still detailed, being for a consultation by a specialist. The first issue a physician addresses in a note is why the patient is in the hospital, or alternatively, why am I seeing this patient. Next, the history of the present illness and current medications with pertinent positive and negative symptoms are recorded. The balance of the history contains, in varying amounts, the past medical history, social habits, familial disease history and a very general review of organ systems. Abbreviations are often used to describe symptoms, past medical problems and social habits. See Table A. The physician then turns attention to the physical examination, beginning with vital signs (pulse rate, blood pressure, respiratory rate and temperature) and a brief description of the patient’s demeanor. Starting with the head and working downward, the physician makes observations about each organ and organ system. Where possible, the physician should inspect, palpate, auscultate and percuss the body part being examined. This is another area of the note in which abbreviations, most of which are not derived from latin, abound. The results of laboratory and diagnostic testing are the next item incorporated into a doctor’s evaluation. Every admission note should contain the results of the patient’s complete blood count (CBC), blood chemistries (SMA), bleeding profile (PT/PTT), urinalysis (UA), electrocardiogram (EKG) and chest x-ray (CXR). Following the physical findings and lab results, the physician lists the patient’s medical problems and sets forth the diagnostic work-up planned for those problems. After the admission note, physicians write daily progress notes in the hospital chart that follow an abbreviated version of the above. These are sometimes referred to as “SOAP” notes – a listing of the patient’s Subjective complaints, a listing of Objective physical findings and lab results, the Assessment of the current medical problems and the continuing Plan for treatment of each identified problem. Interspersed with the progress notes are consultation notes by other physicians and health care providers, such as social workers. Each individual who writes a note in the chart focuses on the issues relevant to the visit – e.g. an orthopedic consultant focuses on the history, physical and objective data relevant to the patient’s musculoskeletal problem and may not even address medical problems being handled by other treating physicians.

Operative Procedures

If one is not aware of the different notes, orders and reports which are required for a surgical procedure, it is easy to miss important information or to see that certain information is missing from the record. Before the patient goes to the operating room, there should be a Pre-op Note and a Pre-anesthesia Note in the Progress Notes. The Pre-op Note is written by the surgeon or house physician and generally includes a description the patient’s surgical problem, the planned surgical procedure, the necessary pre-op lab results, chest x-ray findings, and the consent which has been obtained. The Pre-anesthesia Note records the anesthesiologist’s evaluations of the patient in preparation for surgery. The Pre-op order is written separately on the Order Sheet by the surgeon or house physician and generally begins with “NPO p MN” (nothing to eat after midnight). It usually includes an order to “prep and shave” the relevant area of the body, to administer intravenous fluids, to give pre-op medications and to have the patient “void on call to OR”. Upon arrival in the operating room holding area, the OR nurse fills out an Operative Checklist that confirms the patient’s identity, that consent has been obtained and that the necessary pre-op lab results are in the chart. During the operation, the anesthesiologist keeps an Anesthesia Report, which records a minute by minute account of the patient’s vital signs, all medications given and significant events. An Intraoperative Log is kept by the circulating nurse which records information about supplies used during the operation, such as the sponge and needle count. These documents are generally kept together as Operative Records. Immediately after surgery, the surgeon writes a Post-Op Order on the Order Sheet and a handwritten Operative Note in the Progress Notes. The Post-Op Orders contain the instructions for the recovery room nurses to follow. The Operative Note documents the pre-op and post-op diagnoses, the surgical procedures performed, the operating surgeon and assistants, the drains left in the patient, the EBL (estimated blood loss), any complications and the condition of the patient when sent to the Recovery Room. The Post- Anesthesia Record documents events in the Recovery Room, such as the patient’s vital signs, and is kept with the Operative Records. A Post-Op Note is then written by the surgeon or house physician in the Progress Notes after the patient has been stabilized and returned to the floor. The Operative Report is dictated later but medical information by different members of the health care team allows accurate cross-checking. It is precisely because many different health care providers participate in the creation of the hospital chart that omissions and alterations of hospital records are detectable. By understanding the type and structure of information contained in a hospital chart, one can effectively analyze and answer critical medical questions concerning the client’s case. Whether obtaining an overview of the client’s injuries or evaluating the standard of care provided, you should know what information you are looking for, where you should look for it and when it should have been recorded.

Table A: Common Meanings of Abbreviations in Medical Records:

  1. AKA above knee amputation
  2. AF afebrile (without fever)
  3. AOB alcohol on breath
  4. ASHD arteriosclerotic heart disease
  5. BKA below knee amputation
  6. CABG coronary artery by-pass grafting
  7. CAD coronary artery disease
  8. CHF congestive heart failure
  9. CM cardiomegaly (abnormally large heart)
  10. COPD chronic obstructive pulmonary disease
  11. CRF chronic renal failure
  12. CVA cerebrovascular accident (stroke)
  13. CXR chest x-ray
  14. DOE dyspnea on exertion
  15. ESRD end stage renal disease
  16. ETOH alcoholic
  17. FFP fresh frozen plasma
  18. IDDM insulin dependent diabetes mellitus
  19. GWNL grossly within normal limits
  20. MI myocardial infarction
  21. NAD no acute distress/no acute disease
  22. NKA no known allergies
  23. OBS organic brain syndrome
  24. PCTA percutaneous transluminal angioplasty
  25. PRBC packed red blood cells
  26. PVD peripheral vascular disease
  27. PUD peptic ulcer disease
  28. S/P status post
  29. SOB shortness of breadth
  30. VSS vital signs stable
  31. WDWN well developed, well nourished
  32. WNL within normal limits

A. Leone, Interpreting Medical Records, 4 N.J.L. 1275 (1995).