Congratulations, Personal Injury Chiropractor Daytona FL you now have a stack of medical records eight inches high that you either subpoenaed or your client provided! What now? The purpose of this article is to save the personal injury attorney some time and anxiety, and hopefully, help you to dig out the key information.

As when you are Injury Pain Treatment in Daytona FL confronted with any task, it helps to first have a clear idea of what your objective is, and then work from the largest part of the task down to the finer parts. To begin, and even before you obtain the medical records, it will be most helpful to first have the client complete a medical questionnaire, so that you have a good idea of what records you will need to request.

A. READ THE TYPEWRITTEN RECORDS FIRST

Once you obtain the records, your first task is to look at the ER "History and Physical" records, if there are any, and then to search your stack of records for any typewritten reports. Ignore all handwritten notes for now. For example, "Discharge Summaries" and "Consult Reports" are invaluable because they quickly summarize the case and point out for you where you will need to look next. Be aware that a "discharge summary" may simply refer to a patient being "discharged' from one unit in the hospital, such as the emergency room (ER) or intensive care unit (ICU), and transferred to floor care or some other unit within the same hospital. So there may be more than one "discharge summary' for the same patient.

You will now want to see if there are any "objective" findings in the ER records or consult reports. "Objective" can mean different things to different medical experts, but basically "objective" refers to findings which are not under the voluntary control of the patient. For example, an x-ray of a fracture is an 'objective" finding since it will show an actual picture of the fracture.

Less obviously "objective" is an x-ray of the neck that shows a "loss of cervical lordosis" or a "straightening of the cervical curve." The cervical spinal column in the neck has a natural curve, and a loss of this curve may show that the neck was going into muscle spasm and thereby caused the neck to involuntarily straighten.

"Spasm" is the involuntary tightening of muscles and is frequently associated with strain/sprain type injuries and pain. Healthcare practitioners, such as chiropractors and physical therapists, are trained to feel muscle spasm when they examine a patient. In particular, if you see a notation of asymmetric spasm, this might be a more reliably "objective" finding. For example, try tensing the muscles of just one side of the back of your neck, and you will realize just how hard it would be to fabricate such a finding.

You should now look through the records for whatever radiology reports are available. Fortunately, these are almost always typewritten and easy to read. Look for key words such as "acute" which indicate that the injury happened during the car crash. When looking at a spinal CT or MRI scan report, look for terms that indicate that the nerves are pinched, such as with an "impingement," or that something is rubbing up against the nerves as when something is "effaced." Disc bulges or protrusions are obvious, but also look for less obvious things, such as an "annular fissure" or a "torn annulus." A simple annular tear may not seem like much, but this tear in the spinal disc can be quite painful and very difficult to treat. A finding of an annular tear is something to bring up with your neurology expert for a further opinion.

Much less reliable will be the intake notes as to how the incident happened. For a vehicle collision, the doctor will want to know the patients initial symptoms during the crash, but will not be concerned with who was at fault. It is still worthwhile to look for in the intake records, particularly if there is no police report, to at least get the plaintiff's recollection of events close to the time of the incident. However, be forewarned that the caregivers who do follow-up care will frequently just quote the intake notes, along with any inaccuracies, when beginning their own chart notes.

Look for things that may require follow-up care. For example, "ORIF" is simply jargon for "open reduction internal fixation" surgery to repair a broken bone using surgical screws. So in that instance, you would continue to search the typewritten records to see if there is anything about how long the cast (if any) was in place; if a course of physical therapy was started after the cast was removed; and if there were any adverse reactions to the surgical screws. It would not be too unusual to have to remove some of the surgical hardware if it was causing inflammation or some other sort of problem. There should be some indication of such inflammation in the follow-up reports if it existed.

While reading the typewritten or even handwritten notes, look for abbreviations which may easily indicate what is being referred to. For example, "C/O" in the "History and Physical" notes is shorthand for "complaining of." What follows will immediately summarize the patient's complaints as they existed at that time. Similarly, a number "2" with what looks like a degree symbol after it stands for "secondary to." In other words, for example, neck pain "secondary to" a car accident simply means that the onset of neck pain happened after a car accident.

Other abbreviations refer to frequency, such as when an ordered medicine is to be given. QID means four times a day; TID means three times a day; BID means twice daily, and PRN means that the medication, such as pain medicine, is to be taken as often as needed for pain control. "PO" means that the medication is to be given orally. A small "c" with a line over it means "with" and a small "s" with a line over it means "without." Remember that medical records use scientific terminology, so a small triangle means "change," and not "defendant," as it would in law.