​Daniel Williams
Mar 21, 2023
Medical records are like intricate puzzles, each containing vital pieces of a patient’s healthcare journey. For legal professionals, deciphering these records is essential in building strong cases, understanding medical histories, and advocating for their clients. In this blog post, we’ll delve into the world of medical record review, demystifying abbreviations, highlighting key sections, and providing practical tips.
The Anatomy of a Medical Record
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Demographics and Identifiers: The first section typically includes the patient’s personal information: name, date of birth, address, and contact details. Legal professionals should verify the accuracy of these details, especially when dealing with multiple patients or similar names.
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Chief Complaint and History of Present Illness (HPI): Here, we find the reason for the patient’s visit. Legal reviewers must pay attention to the HPI, noting symptoms, duration, and any relevant context. Was it a slip-and-fall accident? A misdiagnosis? The HPI sets the stage for the entire medical narrative.
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Review of Systems (ROS): ROS covers various body systems, from cardiovascular to musculoskeletal. Legal professionals should look for inconsistencies or omissions. Did the patient complain of chest pain but the ROS lacks cardiac-related questions? Such gaps can impact case assessments.
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Past Medical History (PMH): This section outlines the patient’s previous health conditions, surgeries, allergies, and medications. Legal reviewers must identify pre-existing conditions relevant to the case. For instance, a history of diabetes might affect wound healing after an accident.
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Physical Examination (PE): PE notes provide insights into the patient’s physical state. Legal professionals should focus on objective findings—vital signs, palpation results, and neurological assessments. These details corroborate or challenge the patient’s claims.
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Diagnostic Tests and Results: From X-rays to blood work, diagnostic reports play a crucial role. Legal reviewers must understand the terminology (e.g., CBC, MRI, EKG) and assess abnormal findings. Did the radiologist miss a fracture? Was the lab result within normal limits?
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Decoding Abbreviations
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Medical records love acronyms and abbreviations. Legal professionals should keep a cheat sheet handy for common terms:
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SOB: Shortness of breath
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CVA: Cerebrovascular accident (stroke)
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NPO: Nothing by mouth
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PRN: As needed
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Hx: History
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ROS: Review of system
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Tips for Effective Review
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Context Matters: Understand the patient’s overall health context. A seemingly minor detail might be significant when viewed holistically.
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Timeline Clarity: Create a chronological summary. When did symptoms start? When were tests conducted? Timelines help spot inconsistencies.
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Consult Experts: Don’t hesitate to consult specialists (e.g., radiologists, pharmacists) for complex cases.
Conclusion
Medical record review isn’t just about deciphering jargon; it’s about piecing together a patient’s story. Legal professionals who master this art contribute significantly to justice and patient care.
Remember, every medical record holds a piece of the puzzle. As legal professionals, your role is to assemble those pieces with precision and empathy.​