Revealing the Mysteries of the Medical Record
By Bargardi Medical Consulting
Medical Consulting Expert Legal Nurse Consultant
Medical Consulting Expert Legal Nurse Consultant
As an attorney, any time you or your firm handles a case where health, illness, or injury is an issue you are going to need to review medical records. Whether you are a plaintiff or defense attorney, everyone needs to analyze and understand the contents of the medical record, and face it; they can be extensive and seem like a complex mystery.
The CLNC is a nurse or advanced practice nurse that is specially trained and nationally board certified to work with attorneys on medical-related cases and is your secret weapon as a medical insider, who can reveal those mysteries. The key to looking at a medical record is not only reading and understanding the terms that are used and in the record; but more importantly knowing what should be in the record but is not.
For example, you are the attorney for a plaintiff who comes in with a severe complication after a routine outpatient surgery. In this particular hospital the patient is first seen and admitted to the pre-op area where a full assessment, history, physical exam, pre-op teaching, etc. should be done and documented.
The patient then goes to the operating room (OR), from there to the post anesthesia care unit (PACU) for a specified time or until “stable”, from there to a fourth separate area, the ambulatory surgery recovery unit (ASU) from where she is discharged to home or would be admitted if complications occurred.
Of course the patient can be admitted from the OR, PACU or even pre-op if there were problems. Each of these four units has required documentation and standards of care that must be done in each area before they move to the next. Do you as the attorney or your paralegal know what these are?
Do you know where to find them to see if any standard has been breached, and can you imagine the time it would take you to find out and understand these standards before you could even begin to analyze the medical record? Again, this is where a CLNC can save you time and money to do a quick look at the record to see if there is merit, to determine what standards have been deviated from, what duty breached, and what records are missing.
Going back to this case, the surgery went fine, a simple arthroscopic repair on the right shoulder. The complication involved the routine IV placed in the left hand for the surgery. There were discrepancies in the record, documented as left hand in the pre-op and as a new insertion, as should be done. However, the OR reports using the IV, the PACU documents using a left forearm IV, and then the ASU documents using a left hand, new insertion IV. The records show what medications were given, brief mention of hives and itching, treated through the IV with benadryl, and patient determined stable, given discharge instructions for her shoulder and sent home.
The patient returned less than 12 hours later with pain, redness, and swelling in the left arm, testing was done and immediate surgery due to a diagnosis of compartment syndrome. She underwent four separate surgeries for the compartment syndrome and was left with permanent deformity and disability of the hand and arm.
This case involves weeks of medical records staring with the pre-op admission though her eventual final discharge. There are the outpatient records from the original surgery, ER records, and the complicated in-patient records of her progress. Would you know what standards had been deviated, if they were at all? Would you know what records, policies, and procedures to request for production? Do you know what kind of experts you need; do you know what type of surgeon should operate on compartment syndrome, what it is, and the usual prognosis? Would you know what to ask at deposition?
The answer to all of these questions you, as an intelligent attorney with a paralegal, could eventually find out; however it would take a lot of time and effort. Again, this is where you need a CLNC on your team. If you were to contract a CLNC for this case she could quickly screen for merit, because although it seems like a slam dunk, young mother of two, routine surgery, permanent deformity and disability, someone must have done something wrong.
Let me tell you, I could look at the record and find that everything was done by the book, every effort made, every proper documentation, treatment, etc done, and this could still have happened and is just an unfortunate outcome which is rare but happens because there are no guarantees in medicine. On the other hand, I could quickly look at this and tell you there were deviations from standards of care, missing records, and possible tampering of the record.
The CLNC can give you a list of documents and specific records needed in a request for production. She can identify potential defendants, and develop a list of questions for potential interrogatories, and other questions for discovery and deposition.
A CLNC can go to an independent medical exam and help in other ways to anticipate defense strategy. If working with defense do the same and identify proof of malpractice or tampering early so you can try to settle before a trial or prove there is no merit. For either side a CLNC can work this case quickly and efficiently.
One of the biggest assets is that CLNC’s belong to the National Alliance of Certified Legal Nurse Consultants which consists of over 6,000 experts in every field across the country. We have access to enormous databases of current literature and expert witnesses. That’s right, a CLNC can not only quickly identify the type of expert witness you need, but can quickly find you qualified medical and nursing expert witnesses.
This was an example of one case; actually for a CLNC a fairly simple one to go through even though there was at least a 12 inch stack of medical records.
Now imagine you are an attorney or firm that is working on products liability cases or toxic torts, where you get hundreds of cases to review for merit. This is where you really need the help of a CLNC to save you time and money in weeding out cases without merit and revealing the mysteries of those medical records.
Remember, it is not always what is in the record, but what is not and should be that matters the most in any type of medical case. The CLNC can help you discover these mysteries, save you time, money, and win more cases.
ABOUT THE AUTHOR: Anita M. Bargardi MA,MSN,RN,CS,ACNP,CLNC
Anita M. Bargardi MA,MSN,RN,CS,ACNP,CLNC - Over 23 years of experience as an RN including 9 as an ACNP in the hospital inpatient and outpatient settings. Extensive ICU bedside experience as well as in administration, and clinical research. Professionally trained and board certified to review medical-related cases with attorneys, (CLNC). Experience working with JCAHO and other regulatory standards and committees. Unique insight into the inner workings of a hospital from the nursing and medical side as a Nurse Practitioner who had the same credentialing and privileges as the MD’s including prescriptive authority. Knowledgeable on standards of care and able to quickly review medical records for deviations. I’ve written eight publications in peer reviewed medical journals. I have served on 20 different hospital committees, and done a variety of consultant activities from book reviews, clinical system management to start ups for biotech companies.
Copyright Bargardi Medical Consulting
Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.