It’s always good to be reminded of the importance that emergency department (ED) records play in the management of a medical claim.  As we’ve written before:

An emergency room is the first place many go for medical care. And those ED records provide a critical, but complex window into a patient’s health (past and current) and injuries, establishing a medical baseline at the time of the incident.

Once you have a baseline for injury-related data, you can obtain an accurate reading and understanding of the claim.  Remember to review and investigate every section and all of the information in the ER records…from beginning to end.  Be on the lookout for anything that can help you assess Mechanism of Injury issues, merit, alleged relatedness and casualty issues. ED care should be within the known and established protocols for the respective injuries without bias of insurance coverage.

Make sure you have all of the basic ED documentation, including the RN triage sheet, the physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent.  In addition, it’s important to note patient arrival info.  Ask, for example…

  • How did they get to the hospital?
  • Did they go by ambulance immediately or wait a few days?
  • What was their recorded status upon arrival? and
  • What was the patient’s position on the Triage Acuity Scale?

Review the nurse’s bedside notes carefully.

Missing emergency department records ought to raise all sorts of red flags.  In our years of assessing complex cases, we’ve learned that missing records speak volumes!

Compare the symptoms and chief complaint info.  Using the nurse’s triage notes and the physician’s examination and notes, ask, Does the chief complaint match their objective findings? and Do the complaints escalate? Give plenty of weight to the initial complaints and compare subjective complaints to the objective findings, as these should align in some way.

Don’t forget to check pre-existing  conditions and current medications. Any number of prior conditions and medications can impact cognition, balance, bleeding times, perception, and more.  Review ED diagnostic findings and any test results,  Make sure you look for and consider chronic versus acute versus degenerative conditions.

Be linear.  Check the billing charges to make sure the services included in the bill are in the documentation. Ask, Were the services, tests and labs really necessary?;  Does there appear to be over-utilization?; and Are the services appropriate for the reported injury or diagnosis?  Finally, note if the patient left against medical advice or if the ED physician recommended a specific follow-up specialty.  What was the patient’s condition upon discharge?