Review ER Records from Multiple Angles

Reviewing emergency room documentation can be challenging.  Gathering and assimilating the appropriate information from ER reports represents a crucial step in evaluating a case, relatedness and specific injury issues.

Learn your basic ER documentation and how it all fits together! Follow these tips.

  • A patient’s medical history can disclose pertinent details regarding his current/prior condition.
  • Review medical authorization forms personally signed by the patient.  These can offer critical insight into the case and provide access to the patient’s past medical records without violating HIPAA regulations.
  • Review ER records against other physician’s notes, prior surgeries/tests and EMS records, to determine whether the complaint relates to past symptoms or issues.
  • You can learn a great deal about a patient’s medical state based on the physician’s notes.   Also be aware that new findings/complaints can develop after ER discharge and all the more reason why a close review of the initial ER record is important and follow up on the records is important.
  • Do ordered tests match completed tests?What was specifically ordered?  Was the physician trying to rule something out or confirm a clinical finding or suspicion?  Did the physician NOT order testing, despite the injured party’s request for it?
  • Did the injured party complete the ordered diagnostic tests?
  • Sometimes confirmatory testing will have to be done with in a specific time parameter, so follow the order trail and request test/lab results.
  • Review discharge instructions and note how/if/when the injured party complied. Compliance issue can greatly impact the file/case. Also remember that patient does need to take responsibility when following doctor orders.

~Kari