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How to mine the medical records: you can discover a wealth of information in the mountains of paper that hospitals produce every day - if you know where to look.

Article Excerpt
The foundation for most medical negligence cases is the patient's medical chart, but the official chart is only part of the patient's hospital record. In fact, the case may turn on a document that will never find its way to the chart. Understanding how hospitals work will help you determine what records are available, how they are related, and how to use them to analyze the merits of a medical negligence action.

Records at hospitals are not prepared in a vacuum, but rather are the product of a well-designed system set up to ensure adequate record-keeping. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredits nearly all U.S. hospitals (a few are not accredited). To be accredited by the JCAHO, hospitals must set up their medical records departments and keep their records according to JCAHO standards.

The 2004 standards cover the generation and maintenance of medical records in a chapter titled "Management of Information)" The chapter includes standards on information-management planning, confidentiality and security, information-management processes, information-based decision-making, and patient-specific information.

The latter section requires that hospitals keep a history and physical examination record, an operative report, a consultations record, a discharge summary, and other detailed patient information. The record must contain "sufficient information to identity the patient; support the diagnosis/condition; justify the care, treatment, and service; document the course and results of care, treatment, and service; and promote continuity of care among providers." (2)

In addition, many states have specific regulations--promulgated under statutes that govern hospital licensure--that detail how records must be kept. Some state regulations are so specific that they describe the nature and extent of reporting, outline the timeliness of record-keeping, and even exact penalties for noncompliance.

Consistent with JCAHO policies and state regulations, hospitals must develop written policies and procedures regarding medical record-keeping in their institution, including how medical records are generated, maintained, and ultimately stored.

Typically, when faced with a deficient record, defendants resort to the time-honored excuse that "we were too busy taking care of the patient to generate the kind of detail this lawyer expects." Attorneys handling medical negligence cases must defuse this defense from the beginning.

Virtually every nurse, nurse manager, and physician will agree that medical records are a fundamental means of communication among health care professionals and are required to protect...

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