Obtaining and Interpreting Hospital Records

Obtaining Hospital Records

First, when interviewing the client, a Miami personal injury attorney needs to identify all medical providers that provided treatment or performed diagnostic studies for the client. Next the attorney will request all medical records. In order to do this, the client will have to sign a HIPAA form. HIPAA is an acronym for the Health Insurance Portability and Accountability Act – it is the federal law that is designed to protect a patient’s medical records. Even as an attorney – I cannot obtain another’s medical records without their express, written consent. The HIPPA authorization will (i) describe the information sought; (ii) name the person authorized to disclose the medical information; (iii) include the name of the person who will receive the requested information; (iv) describe the purpose of the request; (v) include an expiration date; and must (vi) include the signature of the individual authorizing the release of his/her medical information.

Doctors, hospitals, and medical groups – may (purposefully or not, depending on if they are the target of a claim or law suit) try to only provide what is specifically asked for – this is why the request will be as broad and inclusive as possible.

Interpreting Hospital Records

If you are struggling to interpret medical records, google can be an invaluable resource. But there may be hundreds of pages of information. It will be helpful to review discharge summaries, history and physical examination sections first as these sections will provide a summary of what transpired. The details are important, so next it will help to review progress notes (which will document the most recent findings and review diagnostic tests that were performed).

There will be a plethora of medical abbreviations that will confuse most people who are not medical professionals. As a Miami personal injury attorney, here are some of the most often used medical abbreviations that I come across:

  • Dx – diagnosis;
  • Fx – fracture;
  • Hx – history;
  • Rx – prescription;
  • ADL – activities of daily living;
  • ad lib – as desired;
  • amb – ambulatory;
  • BR – bed rest;
  • BP – blood pressure;
  • HR – heart rate;
  • TPR – temperature, pulse, respirations;
  • PEARL – pupils equal and reactive to light;
  • VS – vital signs;
  • RR – respiratory rate;
  • Ca or CA – cancer;
  • CHF – congestive heart failure;
  • COPD – chronic obstructive pulmonary disease;
  • CVA – cerebral vascular accident;
  • I&D – incision and drainage;
  • BRP – bathroom privileges;
  • BG – blood glucose;
  • ROM – range of motion;
  • BUN – blood urea nitrogen;
  • Ä€ – before;
  • P (with line over it) – after;
  • Ac – before meals;
  • Pc – after meals;
  • BID – 2x per day;
  • TID – 3x per day;
  • QID – 4x per day;
  • Q – every;
  • C (with line over it) – with;
  • S (with line over it) – without;
  • pt – patient;
  • SBAR – situation, background, assessment, recommendation;
  • SOB – shortness of breath;
  • TKO – to keep open;
  • TKVO – to keep vein open;
  • WA – while awake;
  • WNL – within normal limits;
  • OT – occupational therapy;
  • PT – physical therapy;
  • pt – patient;
  • NKA – no known allergies;
  • NKDA – no known drug allergies;
  • N/V – nausea/vomiting;
  • PH – past history;
  • PMH or PMHx – past medical history;
  • FH or FHx – family history;
  • Post-op – post surgery;
  • Pre-op – pre surgery;
  • PRN – as needed;
  • I&O – intake and output;
  • HOB – head of bed;
  • Fr – French (a urinary catheter size);
  • dsg – dressing;
  • DNR – do not resuscitate;
  • DOA – dead on arrival;
  • CNS – central nervous system;
  • SL – sublingual;
  • PR – per rectum;
  • IV – intravenous;
  • IVP – intravenous push;
  • SUPP – suppository; PO – orally;
  • IM – intramuscular;
  • ID – intradermal;
  • S.G. or spgr. – specific gravity;
  • FBS – fasting blood sugar;
  • H&H or hgb & hct – hemoglobin and hematocrit;
  • K+ – potassium;
  • Na+ – sodium;
  • PLT – platelets;
  • PT – prothrombin time;
  • PTT – partial thromboplastin time;
  • U/A urinalysis;
  • WBC diff – white blood cell differentiation;
  • D5W – dextrose 5% in water;
  • NS – normal saline 0.9%;
  • BG – blood glucose;
  • BUN – blood urea nitrogen;
  • CBC – complete blood count;
  • CXR – chest xray;
  • EKG or ECG – electrocardiogram;
  • UTI – urinary tract infection;
  • ICU – intensive care unit;
  • CCU – coronary care unit;
  • PACU – post anesthesia care unit;

To further assist you, we have described the most commonly used medical directional terms here.

If the action is a medical malpractice case, the nurses’ notes will be extremely important. The nurse’s notes will detail their communication with any physician who examined their assigned patient in addition to reviewing how the patient is progressing during their stay at the hospital. It is a lack of communication between each health-care professional that is often the cause of medical negligence.

It will be important to review what tests were ordered, when was the test completed (note the time between a test being ordered and a test being completed can be very important), what was the test result?, if the test returned abnormal findings, how and when did the appropriate doctor respond?

If the client has been involved in any other accident – especially if it involved a claim (i.e. slip and fall, auto accident, Miami medical malpractice, and workers-comp claims), we will want to request those records as well.

If you would like to speak to a miami personal-injury attorney, please call 800.379.TEAM and ask for Jason Neufeld or he can be emailed directly at jneufeld@nkplaw.com.

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