Litigation Session II 10:45 INTERPRETATION OF MEDICAL RECORDS JANE HERON, RN, BSN, MBA

Transcription

1 Litigation Session II 10:45 INTERPRETATION OF MEDICAL RECORDS JANE HERON, RN, BSN, MBA NJ Paralegal Convention October 19, 2012

2 Looking for clues to what really happened Presented by Jane D. Heron, RN, BSN, MBA, LNCC What is the MOST important step in analyzing medical records? Hint 1

3 What is the MOST important step in analyzing medical records? ORGANIZE THE RECORDS FIRST!! Reasons to organize the records FIRST You know what records you have Reasons to organize the records FIRST You know what records you have You know early what records are missing 2

4 Reasons to organize the records FIRST You know what records you have You know early what records are missing You can identify duplicate records Reasons to organize the records FIRST You know what records you have You know early what records are missing You can identify duplicate records You, your attorney, and your experts can go through records more efficiently Reasons to organize the records FIRST You know what records you have You know early what records are missing You can identify duplicate records You, your attorney, and your experts can go through records more efficiently You can identify inconsistencies in the records 3

5 Reasons to organize the records FIRST You know what records you have You know early what records are missing You can identify duplicate records You, your attorney, and your experts can go through records more efficiently You can identify inconsistencies in the records You may find additional providers Reasons to organize the records FIRST You know what records you have You know early what records are missing You can identify duplicate records You, your attorney, and your experts can go through records more efficiently You can identify inconsistencies in the records You may find additional providers You may identify other potential defendants Reasons to organize the records FIRST You know what records you have You know early what records are missing You can identify duplicate records You, your attorney, and your experts can go through records more efficiently You can identify inconsistencies in the records You may find additional providers You may identify other potential defendants Save time and money if done before scanning and Bates stamping 4

6 What records do you request? It depends on the type and location of case. Examples: Medical malpractice EMS, ER, hospital, doctor s office, clinic, outpatient surgi center, dialysis center, correctional facility, etc. Personal injury hospital, clinic, work, public place What records do you request? Always request a certified copy of the records What records do you request? Always request a certified copy of the records Current and past medical providers 5

7 What records do you request? Always request a certified copy of records Current and past medical providers Prescription history/pharmacies What records do you request? Billing and insurance payment records often hold clues to important information including: Records that may be missing Care/treatment that was delivered but unreported, or reported as done but never was! 6

8 What is the MOST important step in analyzing medical records? ORGANIZE THE RECORDS FIRST!! Helpful hints for organizing medical records Be consistent organize records the same way each time Helpful hints for organizing medical records Be consistent organize records the same way each time Put records in chronological order oldest to most current 7

9 Helpful hints for organizing medical records Be consistent organize records the same way each time Put records in chronological order oldest to most current Keep like records together Helpful hints for organizing medical records Be consistent organize records the same way each time Put records in chronological order oldest to most current Keep like records together Take the time to make sure records are in the right direction Helpful hints for organizing medical records Be consistent organize records the same way each time Put records in chronological order oldest to most current Keep like records together Take the time to make sure records are in the right direction Make sure you have the right patient s records! 8

10 Helpful hints for organizing medical records Be consistent organize records the same way each time Put records in chronological order oldest to most current Keep like records together Take the time to make sure records are in the right direction Make sure you have the right patient s records! Be VERY careful about shredding records you think are duplicates Helpful hints for organizing medical records Be consistent organize records the same way each time Put records in chronological order oldest to most current Keep like records together Take the time to make sure records are in the right direction Make sure you have the right patient s records! Be VERY careful about shredding records you think are duplicates Notice missing pages/pages that don t belong together. Components of hospital records Emergency Medical Services (EMS) Emergency Department Admission documents History & Physical (physician) Physician orders Progress notes (may be MD or multidisciplinary) Nursing records (includes initial patient assessment) Consultations Medications (medications, IVs, transfusions) Operations/Procedures (includes consents; Labor & Delivery) 9

11 Components of hospital records Diagnostic testing (includes lab, radiology, EKG) Graphic records (e.g. vital signs, weights, intake/output) Nutrition Therapies (includes Occupational, Physical, Respiratory, Speech) Case Management Discharge summary Discharge instructions Other : may include legal documents such as living wills/healthcare proxies; correspondence; pre admission testing; records from other providers, etc. Components of physician office records Intake forms Progress notes Correspondence Diagnostic testing Home care records Hospital records/procedure reports Other providers records Phone call logs/messages Prescriptions Components of physician office records Therapies (e.g. PT, OT, etc.) Billing records/insurance OB prenatal records 10

12 Components of nursing home records Face sheet Admission records (includes transfer forms; billing) MDS/RAP (Minimum Data Sheet/Resident Assessment Protocol) Care plan History & Physical (physician) Consultations Physician orders (includes restraint orders, DNR) Progress Notes /Multidisciplinary Notes Nursing notes (includes nursing admission assessment, narrative notes, risk assessments) Components of nursing home records Medications/Treatments Diagnostic testing Rehabilitation/Therapy Nutrition Social Services Miscellaneous Search for Key Information found in medical records Medical history Pre existing conditions Current medications Providers past and present Other unreported injuries Entries that leave you shaking your head 11

13 11 7 shift Distended, rare bowel sounds Conflict Between Nurses Notes and Doctor s Notes: Abdominal Assessment 11 7 shift Rare bowel sounds 3 11 shift Tender 7 3 shift Severe pain 11 7 shift Distended, firm, hypoactive bowel sounds 3 11 shift Tender 7 3 shift Abdomen distended, firm 3 11 shift Abdomen distended, firm 7 3 shift Abdomen firm, tender K E Y Doctor s Notes Nurses Notes 11 7 shift Abdomen distended 12/11/10 12/12/10 12/13/10 12/14/10 12/15/10 10:15 a.m. No time 8:00 a.m 8:30 a.m No time Soft, bowel sounds present Less tender, bowel sounds present Pain decreased, less distended, tender, bowel sounds normal Pain decreased, soft abdomen More distended abdomen, patient is trying to minimize symptoms 34 Helpful hints for sending records to experts Don t send partial records to experts Helpful hints for sending records to experts Don t send partial records to experts Don t highlight or alter records sent to experts 12

14 Helpful hints for sending records to experts Don t send partial records to experts Don t highlight or alter records sent to experts If providing a hard copy, print the records single sided 13

15 Electronic Medical Records 41 Error Prone Abbreviations The Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) have developed a list of abbreviations, symbols, and dose designations that should NOT be used in orders and medical records. 14

16 43 Quality of Information 44 What do you need to request? Ask for the metadata or audit trail or query audit trail or medical record review inquiry Ask for paper and electronic data Ask for PHI (Protected Health Information) disclosure log 45 15

17 What do you need to request? Ask for the physicians orders as they originally appeared on the computer screen Ask for the data dictionary 46 EMR Considerations 5 Legal Issues Surrounding Electronic Medical Records by Molly Gamble, January 19, 2012 ( issues/5 legal issues surrounding legal surrounding electronic medical records.html) Red flags for possible tampering 16

18 Charting Bloopers: The patient refused an autopsy. 17

19 Charting Bloopers: The patient refused an autopsy. Large brown stool ambulating in the hall. Charting Bloopers: The patient refused an autopsy. Large brown stool ambulating in the hall. He was eating his tray so I didn t examine him. Charting Bloopers: The patient refused an autopsy. Large brown stool ambulating in the hall. He was eating his tray so I didn t examine him. On the second day the knee was better and on the third day it disappeared completely. 18

20 Charting Bloopers: The patient refused an autopsy. Large brown stool ambulating in the hall. He was eating his tray so I didn t examine him. On the second day the knee was better and on the third day it disappeared completely. Admitting diagnosis: gang green Resources Medilexicon: National Center for Biotechnology Information: Md Medscape: Labtests Online: Pogofrog: Resources Institute for Safe Medication Practices: Food and Drug Administration: Th J i C i i The Joint Commission: Centers for Medicare & Medicaid Services (CMS): Radiology Testing Information: 19

21 Thanks so much for your time and attention! Jane D. Heron, RN, BSN, MBA, LNCC Legal Nurse Consultant Certified Med League Support Services, Inc. 260 Liberty Court, Suite 200 US Highway 202/31 Flemington, NJ

22 Determining What Medical Records You Need By Jane D. Heron, RN, BSN, MBA, LNCC Decisions about what medical records to obtain may be driven by financial considerations. Attorneys may need to limit how much money will be spent to obtain records, particularly if records are extensive and the attorney is funding record retrieval costs out of pocket. The following outlines what to request for a particular type of case. The facts of each case will determine whether full certified copies of all records are needed, or abstracts may be sufficient. Full certified copies of medical records relating to where the alleged medical malpractice occurred are needed to complete an evaluation of the merits of a claim. A. Medical malpractice cases A host of records may be relevant in a specific case. Depending on the circumstances, of the claim, the attorney should examine: Hospital; emergency room; or emergency center records where the injury was initially treated: a) Emergency medical services records (ambulance or medical intensive care unit/micu) b) hospital records that relate to treatment and surgery c) records of physicians and specialists who examined or treated the plaintiff before and after the incident; d) outpatient imaging (x-rays; MRI scans; CT scans and so forth); e) any outpatient labs where blood work or other tests (EMG; EKG, and so forth) were done; f) inpatient and outpatient rehabilitation records including physical therapy; occupational therapy; and so forth; g) outpatient pain treatment centers; h) the actual radiographs and reports that relate to the injury; i) the actual pathology specimens and reports that relate to the injury; j) billing records; k) visiting nurse home care records; l) mental health; substance abuse records and HIV records;

23 m) autopsy report n) nursing home records 2. Personal injury cases In addition to the records and information outlined for medical malpractice cases, the workers' compensation file, automobile "no fault" file, and work-related records may be requested. It is important for the attorney to be fully aware of the plaintiff s pre-existing medical conditions. A subsequent injury may aggravate a pre-existing condition. The attorney may discover as a case proceeds, that the plaintiff experienced injury from a prior accident that resulted in even worse injuries than the subsequent accident. Relevant information about medical conditions may not be shared by the plaintiff with the attorneys, but may be documented in medical records. For this reason, to avoid surprises, prior medical records should be obtained. 3. Birth injury cases In addition to the records outlined in other medical malpractice cases, you should request: a) mothers' and babies' birth records b) fetal monitor strips* c) ultrasound tape and reports d) biophysical studies e) records of the obstetrician, clinic, or midwife who rendered prenatal care, including any laboratory tests, ultrasound, amniocenteses, and biophysical profile reports *Fetal monitor strips are an electronic print out that is a permanent part of the mother's birth record. If these are destroyed, it is spoliation of evidence. Hospitals may store these strips separately from the rest of the record in the labor and delivery department or other sites. 4. Wrongful death cases In addition to the records listed for medical malpractice cases, the death certificate and autopsy reports are valuable. The autopsy report should include preliminary and final reports including any special staining and testing such as drug screening. Actual pathology material including block, slides and stained slides may be obtained at a later date. Some laboratories require that recuts of slides be made from the tissue block instead of releasing the original slides. If the patient s organs were donated, there may be clinical records generated by the organ donation agency. These records often contain crucial information about events leading up to the donor s death. In some cases, health care providers are far more frank and accurate in reporting the exact sequence of events to the organ bank than they are in documenting the patient s care in the chart. (Frickleton, 2004) References Frickleton, How to mine the medical records, TRIAL, May 2004, p. 62

24 Jane D. Heron, RN BSN MBA LNCC has been a registered nurse for over thirty years. She earned her Bachelor of Science in Nursing from Columbia University and her Masters in Business Administration from Missouri State University. Her clinical background is diverse and includes cardiac rehabilitation, Emergency/Trauma, cardiac catheterization and general surgery. She has worked as a legal nurse consultant for over ten years. Jane has also worked in the finance industry and does volunteer work for the Health Ministry at her church. Jane is a member of the American Association of Legal Nurse Consultants (AALNC). She served on the Board of Directors for the NJ chapter of AALNC for about five years, and is a past president. She is a member of the National Alliance of Medicare Set Aside Professionals (NAMSAP). Jane works as a full-time legal nurse consultant at Med League Support Services, LLC. Jane understands how a legal nurse consultant can play a key role in a variety of settings.