By Catherine Bertram, partner (firstname.lastname@example.org)
One of the key tasks we initially perform when investigating a case involving
malpractice or abuse at a health care facility is a thorough review of
the medical records. At our firm we have two attorney who have both worked
in hospital settings so we are quite familiar with medical records. Catherine(“Katie”)
Bertram is a partner at the firm and was previously the Director of Risk
Management at Georgetown Hospital. Jackie Colclough is a nurse-attorney
with the firm who has a wealth of experience including work as labor and
delivery nurse in a local hospital.
Here are a few basic tips to keep in mind when looking at records:
The first task is to review the records and try to make sure you have a
complete set. Often, the records are incomplete. We check to make sure
we have an initial History & Physical, Orders, Physician Progress
Notes, Nursing Notes, Laboratory Data, Radiology Reports, Operative Notes,
Operative Records/Consent Forms, Pathology, and a Discharge Summary.
Medical Records for pregnant patients are quite different. We have extensive
experience with these types of cases as well. In childbirth cases you
will also have to review the prenatal records from the mother’s
office visits before the delivery. It is key to obtain the Fetal Monitor
Strips (FMS) or Fetal Heartrate Strips (FHR) which demonstrate the baby’s
heart rate relative to the mother’s contractions. This is often
critical in determining if the doctor acted promptly to deliver the child
and avoid injury to the child. You will also need the child’s chart
and the operative delivery records.
INITIAL HISTORY & PHYSICAL
Doctors are required to write a detailed note within 24 hours of a patient’s
admission. This note is often referred to as the “H&P.”
This is a good place to start in your review since it usually provides
a history of the patient’s present condition and symptoms, past
medical and surgical history and any significant labs or imaging results.
The note also usually includes a detailed plan for the patient.
Physicians have the responsibility and authority to order medication, labs,
imaging and other services that the patient or nursing home residents
need. We check these orders to see what medication or services or consults
have been ordered for the patient. The orders should have a time and date
and should be legible. It should also have some indication that the R.N.
acknowledged receipt and review of the order and that it has been carried
out. Some special order sheets may also be included like a patient controlled
analgesia record (“PCA”) which is utilized if the patient
has a pain pump which allows medication to be self-administered at regular
There is another section of the medical record that includes entries by
doctors and nurses, and sometimes others like consultants, physical therapists,
pharmacists and medical residents. This section often looks like a diary
or a log. Most doctors were trained to write their notes in a SOAP format.
The first section should detail the “subjective” concerns
of the patient. The “objective” section follows and this is
where the physician performs a physical examination of the patient and
records the findings. The doctor usually goes through each system of the
body and records the important findings or any changes. The third section
is “assessment” – which is the where the doctor records
his or her thoughts about what is going on with the patient after considering
the subjective complaints and the findings on physical examination along
with any test results or images. The final section is the “plan.”
Here, the doctor writes out the plan of action which should address the
concerning findings and include a plan consultations by other specialists,
medication changes, labs or imaging that is necessary and other follow up.
In some facilities the nurses also write in the progress notes along with
the doctors, but in many hospitals the nurses have their own checklists
and flow sheets where they record their nursing assessments and interventions
from their shift. There may also be other specialized forms for medication
administration (MAR) and for treatment (TAR).
In long term care facilities (nursing homes) we check the skin sheet to
verify if the patient is being turned and the skin integrity is being
checked. *Families are reminded that you must also check your loved one’s
skin yourself. It is key not to let any concerning new “hot spots”
progress. If you see a red spot or a pressure point that is concerning
you need to ask questions and get the staff to act on it right away.
If a patient has a fall or any other abnormal event, the facts and circumstances
should be clearly documented in the progress notes along with a plan.
In most cases, a fall requires prompt physician assessment.
The laboratory report can also give you clues about what is happening with
the patient and what needs to be addressed. A high white blood cell count
(WBC) can be a sign of an infection. The lab usually provides the normal
range for each value on the report so that you can compare the patient’s
value to the normal population. In most labs the patient’s value
will be followed by an “H” or an “L” if the value
is abnormally HIGH or LOW. For lab values that are critical, or an emergency,
the lab also usually includes documentation that the result was called
into either the physician or the nurse assigned to the patient and the
time of that conversation. It is often the case that you can have the
facility print out a laboratory summary report for the patient that shows
the results of the lab data over many days, an entire hospital stay or
over the course of many hospital stays. This can be quite helpful in terms
of tracking trends.
Many patients also have x-rays, CT scans, MRIs, mammograms, sonograms or
other diagnostic imaging performed as a part of their hospital stay. The
written reports from these tests should also be included in the hospital
chart. You can often determine the date and time the image was obtained,
which physician read the image and also if the image is very concerning,
the radiologist often documents that the results were called into the
patient’s doctor or nurse directly and the time of such a call.
The written reports may also suggest additional follow up testing or imaging
that may be required for the patient given the clinical circumstances.
You also need to be careful because occasionally there are initial preliminary
reports of the results and then final reports. If this is the case, you
want to carefully compare the two for any significant differences.
Sometimes imaging is obtained before, during or after surgery while the
patient remains in the operating room so it is important to make sure
you obtain all of that imaging and those reports as well.
If the patient has had a surgical procedure, as an in-patient or in a same
day setting, there are certain required records that will be present.
First, the pre-operative assessments, including anesthesia assessment
and the consent form for the procedure. In some circumstances the patient
will have had an x-ray, a cardiac clearance or certain blood work performed
to make sure it is safe for the surgery. The anesthesia provider will
meet with the patient and obtain a history and assess the patient for
anesthesia risks. Also, the surgeon will talk to the patient about the
surgery and obtain a written consent from the patient.
During the surgery, the healthcare team documents many things. The nursing
staff document on records often called “perioperative” records
that include safety checklists performed prior to surgery, including patient
placement, verification of the surgery to be performed including which
side and which surgery and other safety factors. The nursing team keeps
track of which surgical instruments are used during the surgery and must
account for all instruments at the end of the surgery before the patient
is closed to make sure no instruments or sponges are left in the patient.
The nurse also documents which nurses are in the operating room and when
they leave. At some hospitals the doctor’s entrance and exit are
The anesthesia providers keep a very detailed log of the patient’s
vital signs during surgery, the medication that are given and any response
the patient has to medications.
The surgeon does not take notes during the surgery but is required to dictate
a detailed operative note following the surgery.
The patient is moved to the post anesthesia care unit (PACU) following
most surgeries. This used to be called the recovery room. In most hospitals
the patient is monitored by nurses and the anesthesia team in this area
for a certain amount of time until the anesthetic wears off and the patient
is either ready to leave based on certain discharge criteria or the patient
is transferred to the hospital floor if it is a more involved surgery.
If a patient has cultures take, a biopsy or a surgery that involves removal
of tissue, the patient should have a pathology report. If the report involves
growth results of a culture it can take a few days or several weeks for
the final report to be issued. Oftentimes we have to call and obtain those
final reports as they may not make it to the final paper version of the
DISCHARGE SUMMARY/AUTOPSY RESULTS
Once a patient leaves the hospital, the attending physician is required
to dictate a discharge summary. Most hospitals require the discharge summary
be completed and signed within 30 days of the date the patient leaves
the hospital. This is also true if a patient dies in the hospital. In
that case, you will also want to request any autopsy report or findings.
There are certain circumstances involving patient deaths where the facility
is required to conduct an autopsy based on state law. In other circumstances
a physician may ask for an autopsy or a family may request one. Again,
certain testing may be done as part of an autopsy and the results may
take a few days or have to be sent to a separate lab so make sure you
obtain all of the results that accompany the autopsy. In a medical case,
we often request the entire autopsy file which may include photographs,
tissue blocks and/or pathology slides with special staining.
About the author:
Catherine Bertram is board certified in civil trials and was recently nominated
as a Top Lawyer for Washingtonian Magazine. Ms. Bertram has over 20 years
of trial experience and is unique in that she was formerly the Director
of Risk Management for Georgetown University Hospital so she brings a
wealth of knowledge to her practice including how hospitals should be
run and what doctors and nurses can do to protect patients. She is a partner
with the firm and devotes a majority of her practice to the representation
of patients and families who have been injured or lost due to medical
errors. Ms. Bertram lectures regularly to lawyers and health care providers,
nationally and locally, regarding patient safety, medical negligence and
other related issues. She has also published a chapter in a medical textbook.
She can be reached by email at email@example.com or by phone 202-822-1875
in her office in Washington, D.C.