An Emergency Department is often the first place where the medical record complete or not gets built by medical professionals.
All facts in an injury-related claim or dispute are important. However, some facts are more important than others.
As attorneys, insurance examiners and others know, the emergency department’s medical records often reflect the first time a claimant is seen by a medical professional following a motor vehicle accident or other injury incident. While an EMS may be the first to see a claimant following an injury incident, that’s not always the case.
Once an injured person passes through the ED doors, the nurses and physicians build an emergency department medical record, including…
- Triage notes
- Primary Registered Nurse and ED physician notes
- Physician orders and instructions
- Radiological studies and laboratory tests
- Treatments rendered
- Diagnoses and possible prescriptions and
- Discharge note
The fact is that some of these component parts are often missing from the record or are incomplete. In our years of experience, we’ve encountered all kinds of gaps in the ED record, such as no radiological studies or lab test performed. Sometimes, we we’ve seen the medical records presented for review that are incomplete or ones from which the RN notes may have been omitted or others in which x-rays were ordered but then there are no x-ray reports.
Here’s a closer look at some of our best practices in dealing with ED records…
- The triage or primary RN notes can be the first documentation regarding the Mechanism of Injury and any alleged injuries the claimant reported. The ED physician record may be the next time the MOI is documented. It is imperative to compare these MOI descriptions. If the MOIs differ between providers and or the EMS report this could be considered a great, big red flag. Inconsistent MOIs can make it difficult to render an opinion about any alleged injuries. The claimant could also be attempting to adjust the MOI to fit the symptoms they’re reporting. Additionally, the MOI is the main foundation for the alleged injuries, to the specifics of the MOI must align with the physical clinical data.
- A Legal Nurse Consultant will look at the diagnoses documented and then compare them to the alleged injuries described by the claimant and any testing done in the ED. Any differences between reported injuries and actual objective findings are important in assessing the veracity of the claim. The ED record is important to set the baseline for alleged injuries and can be used for comparison with future visits to other medical providers. This is important especially of there is expansion of symptoms/complaints or additional injuries reported to providers seen later in the treatment timeline.
- Did the injured party follow discharge instructions? For instance, did the person fill prescriptions and follow up with the specified specialist? Failure to do so can not only impact care and recovery, but can indicate compliance issues and severity of injuries.
- Review the billing statements against the narrative documentation to verify and insure that all procedures/care was in fact completed and billed appropriately.
We’ll take another look at this topic in a couple of weeks or so in Part Two. Meanwhile, for more about Mechanism of Injury and why it’s so important when analyzing a claim check out this post and this one.
Litigating injury claims and the importance of ED records were front-and-center recently at the annual 2018 Arkansas Trucking Seminar. Attorneys, insurance examiners and other professionals from across the U.S. met September 18-20 in Rogers, Ark., to share peer-to-peer insights about emerging trends, best practices and current issues.