Medical records: organising and understanding

Paralegals and Trainee Solicitors should be taught how to handle and consider documents effectively early in their career. When dealing with personal injury, clinical negligence, illness or disease claims this may include sorting and considering medical records.

When handling a claim where there is a large volume of medical records it is wise to sort the records into sections. This makes it easier when considering the records and when locating relevant records.

Suggested sections

  1. Computer records
  2. Treatment summary cards
  3. Lloyd George records
  4. Vaccination and immunisation history
  5. Clinical data (eg x-ray results, scan results, blood test results)
  6. Correspondence & miscellaneous

Additional sections can be created if there are a lot of pages of a particular type of record or to have a particular type of record grouped together and easily accessible. Eg, in a NIHL claim it may be convenient to have a section headed “Audiology” or “ENT records.” One needs to think about what sections are needed.

Individual sections should be sorted into chronological order.

After the records have been sorted, they should be paginated in the top right corner (not in the bottom right corner because the records may form part of a Trial Bundle at a later date and need to be paginated in the bottom right corner then). The records should be scanned into the case management system.

A chronology should be prepared summarising the key records and noting their page number. The Paralegal or Trainee Solicitor may also prepare a brief report or a file note outlining what the Claimant claims and the extent to which their account is consistent with the records. Research about the medical problems suffered may also be attached to the brief report or file note. A template report is at the bottom of this blog.

Abbreviations

Abbreviations within medical records may include:

# Fracture

++ Much/many

0 Nil/nothing/none/no

Δ Diagnosis

ΔD Differential diagnosis

ΔΔ Differential diagnosis

↑ Increasing

→ Constant, normal or lateral shift

↓ Decreasing

⊥ Central

1/7 1 day

2/52 2 weeks

3/12 3 months

T-2/40 or 2/52

Term (ie the baby due date) less 2 weeks

T+3/40 or 3/52 Term plus 3 weeks

aa Of each

AAL Anterior axillary line

ac Before meals

ACTH Adrenocorticotrophic hormone

ad Up to

add Adduction

ADH Antidiurectic hormone

ADL Activities of daily living

ad lib To the desired amount

ADP Adenosine diphosphate

AE Air entry

AFB Acid fast bacillus (TB)

AFP Alpha-fetoprotein(α-fetoprotein; also sometimes called alpha-1-fetoprotein, alpha-fetoglobulin, or alpha fetal protein) is a protein that in humans is encoded by the AFP gene. The AFP gene is located on the q arm of chromosome 4 (4q25).

AID Artificial insemination – donor

AIDS Acquired Immune Deficiency Syndrome

AIH Artificial insemination – husband

AJ Ankle jerk

alt dieb Every other day

Al S Alimentary system

Anti-D A medication called anti-D immunoglobulin which can help prevent rhesus disease. It helps  avoid sensitisation, which is when a woman with RhD negative blood is exposed to RhD positive blood and develops an immune response to it.

Agpar Apgar score is a method to quickly summarize the health of newborn children against infant mortality

Applic Applications

aq Water

aq dest Distilled water

aq ster Sterilised water

AR Analytical standard of reagent purity

ARC Aids related complex

ARDS Adult respiratory distress syndrome

ARM Artificial rupture of membranes

ASD Atrial septal defect

AST Aspartate aminotransferase

ATP Adenosine triphosphate

aurist Ear drops

A/V Anteverted

bd Both

BJ Biceps jerk

B.S. British Standard

BO Bowels open

BP Blood pressure

BS Breath sounds; bowel sounds; blood sugar; British Standard

c With

Ca Carcinoma/cancer; calcium

Caps Capsules

CAT scan Computed axial tomograph

cp Compare

CIN Cervical intraepithelial neoplasia, also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer.

CMV Cytomegalovirus is a common virus that is part of the herpes family of viruses.

CNS Central nervous system

CO Complaining of

COETT Cuffed oral endotracheal tube

comp compounded of

COT Cuffed oral tube (used for ventrilating a patient who can’t breathe unaided)

CPD Cephalopelvic disproportion –  occurs when a baby’s head or body is too large to fit through the mother’s pelvis

crem A cream

CSF Cerebro-spinal fluid

CTG Cardiotocography – a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy. The machine used to perform the monitoring is called a cardiotocograph, more commonly known as an electronic fetal monitor.

CVA Cerebrovascular accident

CVS Cardiovascular system

Cx Cervix

CXR Chest x-ray

D Diagnosis

DIC Disseminated intravascular coagulation – a condition in which blood clots form throughout the body, blocking small blood vessels.

dil Dilute

DNA Did not attend; Deoxyribonucleic acid

D&V Diarrhoea and vomiting

DOA Dead on arrival

DOPA Dopamine

DVT Deep vein thrombosis

D/W Discussed with

Dx Diagnosis

ECG Electrocardiogram

ECT Electroconvulsive therapy

EDD Expected date of delivery

emf Electromotive force

EM Electron micrography

emp Emplastrum –  a plaster

enem Enema

EOG Electrooculogram

ER External rotation

ERCP Endoscopic retrograde cholangiopancreatography

ERPC Evacuation of Retained Products of Conception

ERG Electroretinogram

ESR Erythrocyte sedimentation rate

Ex Extension

FB Finger’s breath

FBC Full blood count

FBS Foetal blood sampling

FH Family history

FHH Foetal heart heard

FHHR Foetal heart heard regular

FHR Foetal heart rate

Flex Flexion

FMF Foetal movements felt

FSE Foetal scalp electrode

FSH Family/social history; follicle-stimulating hormone

GA General anaesthetic

garg gargles

glc Gas liquid chromatography

GTT Glucose tolerance test

GFR Glomerular filtration rate

GIT Gastrointestinal tract

GM Geiger Muller

GUT Genitourinary tract

Hb Haemoglobin

HCG Human chorionic gonadotrophin

HCO History of present complaint

hn Tonight (hac nocte)

hs At bed time (hora somni)

HS Heart sounds

HSA Human serum albumin

HVS High vaginal swab

Hx History

ICF Intracelluar fluid

ICS Intercostal space

IgA, IgB, IgG, IgM Immunoglobulins

IJV Internal jugular vein

IM Intramuscular

Implant Implantation

In aq In water

Inj Injections

IP Intraperitoneal

IR Internal rotation

Irrig Irrigations

K Potassium

KJ Knee jerk

KPa Kilopascal, approx 7.5 mm Hg

L Litre

LA Local anaesthetic

LATS Long acting thyroid stimulator

LFT Liver function tests

LH Lutenizing hormone

LIH Left Inguinal Hernia

Lin Liniments

Linc Linctus

Liq Liquid/solutions

LMP Last menstrual period

LN Lymph node

LOA Left occiput anterior

LOC Loss of consciousness

LOL Left occiput lateral

LOP Left occiput posterior

LSCS Lower segment Caesarean section

LSK Liver, spleen, kidneys

m Mix

M Intravenous infusion

mane In the morning

mcg Microgram

MCL Mid clavicular line

mg Milligram

mmHg A millimeter of mercury is a manometric unit of pressure

ml Millilitres

mp Melting point

MSH Melanocyte-stimulating hormones

MSU Midstream specimen of urine

N&V Nausea and vomiting

NAD Nothing abnormal detected

NBM Nil by mouth

Neb A nebulizer/nebuliser is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs; a spray

ng Nanogram

NG Nasogastric; Neoplastic growth

NGT Nasogastric tube

NMCS No malignant cells seen

NOF Neck of femur

N/S Normal size

Occulent Eye ointment

OA Occipitoanterior position

of Daily

OD Outside diameter

OE On examination

OM Every morning

OP Every evening

PR Pulse rate

Pa Pascal

PAS Periodic acid – Schiff reaction

pc After meals

PCG Phonocardiogram

PCV Packed cell volume

PERLA Pupils equal, react to light and accommodation

PE Pulmonary embolism

pes Pessaries

PET Pre-eclampsia toxaemia

ph Acidity/alkalinity scale

PH Past history

PID Pelvic inflammatory disease; prolapsed intravertebral disc

PMH Past medical history

PN(R) Percussion note (resonant)

PNS Peripheral nervous system

PO By mouth

PR Per rectum

PRN As required

PV Per vagina

RBC Red blood cells

Rh Rhesus

rh Relative humidity

RIA Radioimmunoassay

RIH Right inguinal hernia

ROA Right occipito anterior

ROL Right occiput lateral

ROM Range of movement

RPF Renal plasma flow

RQ Respiratory quotient

RS Respiratory system

RT Reaction time

RTI Respiratory tract infection

S/B Seen by

S/D Systolic/diastolic

SEM Scanning electron microscope

SH Social history

SOA Swelling of ankles

SOB Shortness of breath

SROM Spontaneous rupture of membranes

SVC Superior vena cava

SVD Spontaneous vaginal delivery

TCI 2/52 To come in 2 weeks time

TGH To go home

THR Total hip replacement

TID 3 times a day

TJ Triceps jerk

TFTS Thyroid function tests

TSH Thyroid stimulating hormone

U&E Urea and electrolytes

Ung Ointments

UG Urinogenital system

URTI Upper respiratory tract infection

VE Vaginal examination

VF Ventrical fibrillation

VT Ventrical tachycardia

V/V Vulva and vagina

WBC White blood count

The Skeleton

Carpals: Wrist bones

Clavicle: The collarbone

Femur: The thigh bone

Fibula: The calf bone; the outer and smaller bone of the leg below the knee

Humerus: The bone between the shoulder and elbow

Illium: The large broad bone forming the upper part of each half of the pelvis

Ischium: The curved bone forming the base of each half of the pelvis

Metacarpals: Bones in the hand

Metatarsals: Bones in the feet

Patella: The kneecap

Phalanges: Bones in the fingers and toes

Radius: The bone on the outer side of the forearm

Sacrum: A large, triangular bone at the base of the spine

Scapula: The shoulder blade

Skull: Head bone

Sternum: The breastbone

Tarsals: Ankle bones

Tibia: The inner and larger bone of the leg below the knee

Ulna: The inner and larger bone of the forearm

Vertebra: Any one of 33 bones of the spinal column

Template Report

Claimant’s name:

Claimant’s DOB:

Claimant’s age:

Claimant’s occupation:

Introduction

1 or 2 paragraphs summarising the claim.

Records received

Bundle A – GP records up to (date)

Bundle B – Name of Hospital/Trust records up to (date)

Bundle C – Name of Hospital/Trust records up to (date)

Chronology

Date Type of Record Entry Page Number

Discussion

Where appropriate, include comments about:

  • The extent to which the records are consistent with instructions received detailing inconsistencies
  • Limitation
  • Identity of potential Defendants
  • Breach
  • Causation
  • Speciality of experts who may need to be instructed and the reasons why and likely cost (consider consulting your firm’s expert database and attaching CV’s)
  • Questions that may need to be put to experts
  • Questions that may need to be put to the client
  • Missing records or other records that need to be applied for

State your opinion about the prospects of success (or if that isn’t possible, what is needed to be able to assess prospects).

Research

List sources of information and, where appropriate, attach copies of research.

*Thank you to the team at Alexander Harris (now part of Irwin Mitchell LLP), who in the mid to late 1990’s, taught me how to sort and analyse medical records.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this:
search previous next tag category expand menu location phone mail time cart zoom edit close