3 Tips for Attorneys on Emergency Department Records

The emergency department is a whole separate entity on its own even though it is physically connected to the hospital facility.  The state and federal laws that govern the emergency department are not like those other areas within the hospital. The governing laws not only differ, but the hospital operations of the department are like no other unit. 

Tip # 1. When examining a case regarding the emergency department, you must ensure you obtain ALL of the records from the emergency department.  Often attorneys obtain an “abstract” of medical records which is understandable when first trying to evaluate a case, but the full records from the emergency room is not a place to obtain only an abstract.  The nurses’ note are highly valuable to provide the whole picture of the occurrence from what happened with the patient to what the physician or mid-level did or did not do. Do not scrimp on obtaining these records even if the issue is not nursing related, their noted will reveal more than you realize.

Tip # 2.  When obtaining these records, know all of what you need.  There are “separate” areas of the emergency department that will have its own documentation.  For example, the physical location of triage is usually a separate area of the department and will be staffed by a medical provider, usually a RN.  This is typically the entrance point for many patients seen in the department unless arriving via ambulance.  This initial contact with the patient will have its own documentation.  From triage, a patient will then be seen by the “primary nurse” in a separate area from the triage.  This will also entail separate documentation.  Even if the facility is still documenting on paper or in electronic form, there will still be a “triage” document and documentation from the primary nurse (who can be the same). 

Tip # 3. Ensure that you have a medical expert well versed in emergency department evaluations review your records to determine issues with standards of care.  Like I said earlier, the emergency department is a whole separate entity and there are certain standards of care that not every medical provider or attorney is aware of.  For example, I was asked to look at a case that primarily involved the physician and mid-level in the emergency department.  Upon my initial review, I started off with reviewing the emergency department records.  Well, there were huge breaches in standard of care from the nurses. Unfortunately, it was too late to bring the nurses into the lawsuit which would further bring the hospital into the case (they were in due to ostensible agent).      

To discuss your case, email or call Lori at (432) 661-3639 or fill out the contact form on this site.