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 and injuries, establishing a medical baseline at the time of the incident.

We recently looked at the importance of Emergency Department records and what to do in the likely event that there are missing or incomplete records.  Here’s that post.  In Part Two, we’re going back to the basics.

Emergency room visits are on the rise. One study from the American College of Emergency Physicians found that 28 percent of ED doctors polled have reported a spike in the number of cases since the Affordable Care Act took effect. Another 47 percent have seen at least a slight increase.

The costs are on the upswing too, especially for personal injury claims, as hospitals attempt to recoup money thanks to changes in the healthcare system and other factors. In fact, charges can vary wildly – from $4 to care for a sprained ankle to $24,000, according to one study. There is no associated fee schedule with property and casualty claims. This, by default, allows providers to set their own fees with the expectation of full reimbursement.

If you’re reviewing medical records for a case or a claim, here are eight things you need to know.

  1. Emergency Room records provide a baseline for a patient’s injuries. An accurate reading and understanding will supply the objective findings to understand how the injured person fared.  All sections and information within the ER records must be reviewed and investigated in order to assess mechanism of injury issues, merit, alleged relatedness and casualty issues. Remember: The medical records are a snapshot of the medical care.  The care rendered should, in theory, have nothing to do with the payer. The care should be within the known and established protocols for the respective injuries without bias of insurance coverage. However, it’s critical to acknowledge that the filter of insurance coverage does sometimes impact the care documented within an ER record.
  2. Basic ER documentation…make sure you have it all. It includes RN triage sheet, the ER physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent.
  3. Patient arrival info…such as 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? What was the patient’s position on the Triage Acuity Scale? Review the nurse’s bedside notes carefully. You’ll find a treasure trove of information about how the patient behaved, what they said and how they responded to treatments and care.
  4. Symptoms and chief complaint info is key. Compare the nurse’s triage against the physician’s examination and notes. Does their chief complaint match their objective findings? Do the complaints escalate? The initial complaints are always the most accurate. Compare subjective complaints to the objective findings.  These should align in some way.
  5. Check prior medical condition. Don’t forget to check pre-existing conditions and current medications. Any number of conditions and medications can impact cognition, balance, bleeding times, perception, etc.
  6. Diagnostic findings. What are the test results? Consider chronic versus acute versus degenerative. Are there abnormal lab results? Elevated blood sugar? Prolonged bleeding time?  Understand that the rule of thumb is this: A finding should fit what is known. Only when it does not should doctors begin investigating more unusual conditions. And, clearly, not all abnormal findings are directly related to a trauma event.
  7. Examine billing info. Check the charges to make sure the services included in the bill are in the documentation. Ask questions. Were the services, tests and labs really necessary?  Does there appear to be over-utilization?  Are the services appropriate for the reported injury and /  or diagnosis?
  8. Discharge records. At the time of discharge, the medical team will provide information to the patient about diagnosis, post discharge care, medications and follow-up care. Did the patient leave AMA, otherwise known as against medical advice?  Did the ER physician recommend a specific follow-up specialty or PCP, yet the patient went to a different specialty or did not follow up at all?  What condition was the patient upon discharge?

Need more help?

A trained eye can quickly get to the bottom of all of the emergency room tests and procedures. That’s what we do here at MKC Medical Management – helping claims adjusters and attorneys understand complex medical records and information.

KARI

PS:  The panel presentation at the annual Trucking Industry Defense Association (TIDA) seminar went off without a hitch in Austin, Texas, and we got great feedback on our presentation…thanks to my co-panelists, Dave Goldstein and Nicole Spellecy (on the right).  Let me know if you’d like a copy of our TIDA PowerPoint and notes. Our topic, by the way, was “Stop Your Soft Tissue Claim from Spiraling Out of Control.”