The practical and legal considerations of analyzing medical records for personal injury often come down to what Erin E. Murray, president of Medical-Legal Resources Inc., a certified legal nurse consulting firm in Medway, Mass., calls the need to have “a degree in reading chicken scratch” – the ability to decipher the illegible handwriting of doctors.
Murray, along with David A. Ursillo, of the Law Offices of Gregory J. Schadone Ltd., North Providence, spoke at the 2010 Rhode Island Bar Association Annual Meeting June 11 at the R.I. Convention Center. They offered insights into how best to understand the arcane language of abbreviations for medical terminology used in documents such as emergency room records, which is often critical to the successful outcome of a case. More than 100 attorneys attended the session.
As one example, in a case involving a dispute of the extent of injuries from an accident, Ursillo pointed out the notation made under past history by the attending physician on an emergency room report, which read “GSW Chest,” which, he said, stood for “gunshot wound to the chest.” Someone who has had a gunshot wound to the chest, Ursillo said, may have a different threshold for pain and describe it differently.
Ursillo also talked about the importance of making sure that the dates within the medical records are congruent, so that the sequence of events and examinations and follow-up medical care “will make sense to the jury.”
Murray stressed the importance in the capability of lawyers to properly interpret potential medical evidence in such things as lab value grids, from liver function tests to electrolyte and mineral lab values, which are often given in abbreviations and numbers. She recommended a number of resources for what she called “the arsenal of texts” necessary for presentation and understanding of medical evidence. In addition, she provided the attorneys with lists of 17 documents one would expect to find as part of a hospital medical record, and 29 such documents for a nursing home medical record.
Ursillo, in turn, described the importance of properly asking for medical information when approaching the hospitals and billing offices, even including the fees for such information as part of the initial request. He also talked about the importance of being able to obtain medical affidavits in the most comprehensive manner regarding a case.
The legal-education session occurred on the cusp of a major sea change in medical records – the move to electronic medical-record keeping.
The day before the session, Rhode Island Hospital, one of the largest private employers in the state, announced that it had achieved stage six for meeting federal standards for electronic medical records compliance, one of only 105 hospitals nationwide to hold such a designation. The stages are graded from zero to seven.
The goal of electronic medical records is to improve safety and efficiency and reduce costs of medical care. It will enable physicians in different systems and locations to access a patient’s medical record, facilitating a more comprehensive approach to overall care, and eventually providing patients with electronic access to their own medical records.
Rhode Island Hospital is now positioned to receive federal financial incentives under the American Recovery and Reinvestment Act. Newport Hospital, a Lifespan partner, has already received its stage six designation, while The Miriam Hospital is expected to receive a stage six designation later this summer, according to Ellen Slingsby of Lifespan.
Within five years, all major hospitals are expected to be in compliance with the new federal standards or face stiff financial penalties. Annemarie Beardsworth, a spokesperson with the R.I. Department of Health, said that her department is working with physicians and hospitals to encourage the changeover. “Ideally, we would love to see it happen faster than five years,” she said. “But you need to balance that with the reality and practicality of doing that. For large institutions, the switch to electronic medical records is not something that is going to happen overnight or over a weekend.”
The change-over to electronic medical-record keeping was not discussed during the bar-association session.
After the session, Murray talked about what the changes to electronic medical-record keeping will mean for the legal community. “First of all, everything will be typed and legible,” she said, with a laugh. “That will make a big difference.”
Another change, Murray said, is that nothing can be permanently “whited out” in a medical record. Attorneys often white-out different parts of a medical record to place greater emphasis on particular information, she said. With electronic records, however, nothing can be erased. •
