Analyzing Records is crucial to your case.
Analyzing Records for Damages
“The proof is in the pudding.” “The devil is in the details.” You know those expressions – they remind us that cases are won and lost on the details. Carefully analyzing records is a crucial step that shouldn’t be hurried. This process offers vital insights into a patient’s condition following an injury.
This careful examination allows healthcare professionals to piece together the patient’s medical history, treatments administered, and the overall course of recovery.
Besides analyzing records, we should also consider how these serious injuries might impact the patient’s mental health.
This part of his experience is important to understand the total damages. It not only impacts the patient’s life but also puts stress on their family.
Using these psychological evaluations in the full assessment helps us understand the pain involved. This is important for any legal matters related to the case.
Consider this fictitious example:
28-year-old Carter Kennedy was the driver of a car that was T-boned at an intersection when a driver ran the red light. Mr. Kennedy had immediate back and neck pain. His right leg was obviously deformed, with bone protruding through his thigh.
Suppose his attorney hired us to go through the records to determine the damages. This is what we would review:
Prior medical records: What medical problems did Carter have before this crash? We determined he had no prior history of back or neck pain. He was employed as a brick layer and was able to lift , carry and push heavy loads of bricks.
Emergency Medical Services: These records must be requested in addition to the acute care records.
Clearly documented, they mentioned Carter reported neck and back pain at the scene. The team noted he was wearing a seat belt when they first saw him. They recorded, “Possible loss of consciousness.”
Carter was having trouble breathing. The staff used a bag and mask to help him breathe, thinking it was because of broken ribs.
Emergency Department: The EMS squad applied a hard-cervical collar and strapped Carter to a stretcher. When he arrived at the ED, the medical staff assessed him and put him through a series of diagnostic studies. Although he complained of neck pain, the ED physician did not order a neck CT scan.
Instead ordered a head, thoracic spine, and lumbar spine CT scans, all of which were negative. Carter had serious injuries, so he was put on a ventilator right after he got to the emergency department. The emergency department nurse removed the cervical collar without an order. Not ordering a neck CT scan, even though he has neck pain, makes us wonder if the evaluation was done carefully.
This mistake delayed the diagnosis of the neck fracture and caused permanent damage to his spinal cord. These mistakes show how important it is to follow set guidelines and take all patient complaints seriously. This can greatly affect patient outcomes. We told the lawyer that the personal injury case we started with has now turned into a medical malpractice case. These mistakes in care show why it’s crucial to follow established protocols and to take every patient complaint seriously since they can significantly impact patient outcomes.
Progress Notes and Consults: The orthopedic surgeon answered the call from the EDMD. He looked at the patient’s leg and decided to send him to the OR to fix his leg fracture.
Nursing Notes: When Carter reached the recovery room, the nurse noted he was not moving his legs. She assumed the lack of movement was due to the anesthesia and did not report this to the surgeon.
Radiology Studies: The orthopedic surgeon ordered a CT scan of the neck. It showed a burst cervical fracture that had torn the spinal cord.
Therapy Notes: The physical therapist performed range of motion exercises at the bedside.
Care Manager: The nurse in charge of medical care spoke with Carter and his wife. They talked about what to do next and wrote down how upset they were about Carter’s health.
Rehabilitation Records: Carter went to a long-term hospital because he needed a ventilator and could not move.
Home Care Records: With assistance from his wife, her mother, and a caregiver, Carter spent the following two years at home before he passed away due to an infection.
Analyzing Records here will help to illustrate the pain and loss Carter went through during the two years following the crash.
Most physician medical records and even depositions may not capture the impact of pain and suffering.
Nurses are trained to analyze, quantify, summarize and relieve pain and suffering.
In addition to the physical and emotional pain, we must also think about the financial impact of serious injuries. Carter cannot work as a bricklayer anymore. This has hurt his income and put pressure on his family’s finances. The costs for medical care, therapy, and changes to their home to meet his new needs have added to the stress.
Analyzing Records is key for getting a fair outcome in legal cases.
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