Managing the Medicals:
GPS Your Way
Through
Records
Mary Ann Shea JD BS RN
Attorney at Law / Registered Nurse
314.822.8220
MASHEAJDRN @AOL.COM
Take charge
of the sea
of paperwork
Types of Cases With
Medical Issues
The "Obvious"
1. Medical Malpractice
2. Personal Injury
3. Product Liability
4. FELA
5. Workers Compensation
Types of Cases With
Medical Issues
The "Not-So-Obvious"
1. Probate
2. Criminal
3. Domestic
4. Child & Adult Abuse & Neglect
5. Health Care Fraud
Medicalese 101
Medical terms consist of “parts”
- prefix, root & suffix –
Greek & Latin origin
Medical Terms
cephalgia = cephal + algia
endocarditis = endo + cardi + itis
myoma = my + oma
meningitis = mening + itis
nucchalgia = nucch + algia
proctalgia = procto + algia
Medical Abbreviations
• Standard, approved abbreviations
only. (Many institutions have lists
of “approved” medical
abbreviations.)
• Communication in the medical
record is only possible if all abide
by the use of standard
abbreviations.
Getting the Medical Records
• Allow plenty of time
• Be clear what you want – request in
English, not legal-ese
• Don’t ignore the nursing
documentation
• Know statutory fees
• Be nice!
What NOT TO DO
With Medical Records
• Don’t mark on originals
• Don’t assume you can differentiate
one provider’s records from the
others
• Don’t remove individual pages from
the record
• Don’t assume they’re in logical order
What TO DO
With Medical Records
• Make copies
• Keep original separate
• Clearly label them as they come
in
• Train ALL your staff in medical
record management
Managing Medical Records –
“An art and a science”
Identifying Necessary Medical Records
• Don’t scrimp at this step! (Time/$$$)
• Get complete list from client/patient
(Full names, dates, what for, etc.)
• Make a form
• Watch for references in other records
• Contact 3rd party payors for payout info
Key to survival: Knowing
“who writes what where”
• Different parts of the medical record
contain different types of information
• Contrary to popular opinion, you don’t
get the whole story from the Discharge
Summary. (That’s why they call it a
“summary.”)
Hospital record dissection
• Face Sheet – Demographic data, diagnoses,
procedures, codes.
• Consent Forms – General and specific
consents for invasive procedures.
• Autopsy Reports – If the patient died and a
post-mortem was done, useful in
pinpointing the cause of death.
• Discharge Summary – The “high points”
– Good place to start, but don’t stop there.
– Note the date dictated (“d” or “dd”) and the date
typed (“t” or “dt”)
• Compare to date of discharge.
Hospital record dissection
• Emergency Department Reports – If seen in
the ED or transported by ambulance, these
records should also be in the hospital
record.
• Admission History & Physical (H&P) –
Contains the initial impressions about the
diagnosis, which might differ from
subsequent decisions.
• Operative Reports – If the patient had
surgery, the reports of the surgeon,
anesthesiologist and nurses will all be in
this section.
Hospital record dissection
• Physician Progress Notes –
– Familiar to most attorneys
– Vary in detail, but are supposed to
indicate the patient’s current condition
when seen by the physician.
• Consultation Reports –
– Consulting professional will document
the findings in the medical record.
– The primary care physician is ultimately
responsible for orchestrating the care
and treatment of the patient.
Hospital record dissection
• Order Sheets – Physician directions for
the health care team.
• Diagnostic Testing – Contains lab
reports, Xrays, scans, ultrasounds,
EKG’s, EEG’s, etc.
• Ancillary Departments – Respiratory
Therapy; Physical Therapy; Social
Services; Occupational Therapy;
Speech Therapy; etc.
Hospital Record dissection
• Nursing Documentation –
• Many different types of forms.
• Majority of the documentation in the
medical record.
• 24/7 monitoring.
• Forms include: Medication
Administration Records, Intake & Output,
Vital Signs, IV’s, Activities, etc.
• Recorded on Flow Sheets, and/or in
narrative form
• Contains a wealth of information!
Nursing home chart
• MDS
• RAP
• Wound care
• Fall prevention
• MAR
• MD notes
• Nursing notes
• Transfer sheets
Doctor office chart
• Free reign
• Fewer
restrictions/requirements
• Consistency issues
–Provider to provider
–Visit to visit
• Illegible
• Creative abbreviations
Things to look for
• Inconsistencies
• Discrepancies
• Missing info
• DD/DT
• Mystery providers
At some point you find your way…