Section 10 Hospital Records

• Library: Damages 2012

Virtually every minute a patient spends in the hospital is documented. The History and Physical—taken upon admission—not only explains the patient’s condition upon admission but often provides valuable information as to how the accident occurred. The Operative Report, when read to the jury, can provide many details that exemplify just how serious the patient’s injury is, e.g.:

· The type and amount of an organ removed

· The amount of time the operation took and consequently how long a person was under a general anesthetic

· The amount of blood loss

· Just how mangled a particular internal organ might have been as a consequence of the accident

The hospital records also provide a list of all pain medication the patient was given.

Some of the most useful portions of the medical records are the nurses’ notes. The floor nurses on each shift make detailed entries of the patient’s complaints. This chronology often vividly illustrates the pain experienced. Careful scrutiny of the nurses’ notes often indicates things such as the following:

· Complaints of increased pain before the next dosage of narcotics is due or permitted

· Tears, screams, delirium, and other similar conduct

· The nurses’ observations of depression

· Documentation of pain associated with the administration of treatment—i.e., physical therapy

· Embarrassing moments—the patient’s inability to shave, brush teeth, eat, or even walk to the bathroom without assistance

The following is an extract of a set of nurses’ notes from a 24-hour shift in the early hospitalization of a paraplegic accident victim. These notes could be read to a jury.

9-25-2010

4:35 p.m. Patient brought to ICU No. 6.

4:50 p.m. R.N. from recovery room noted incision of abdomen to be bleeding. Call placed for Dr. Smith.

5:00 p.m. Intramuscular medication given in right thigh for discomfort.

5:10 p.m. Dr. Smith returned call; additional pain med given and stat lab ordered.

5:15 p.m. Incision oozing blood.

5:30 p.m. Lab work drawn from ART line. Abdominal dressing changed. Saturated with blood.

5:45 p.m. Left side of face edematous with hematomas. Bruises present on left leg.

6:00 p.m. Family here. Patient flinging arms wildly. Suctioned for scant clear yellow tinge production.

6:40 p.m. Incision continues to ooze blood. Hematoma circular in fashion forming midway down incision.

7:00 p.m. Flinging arms but seems to calm down when talked to.

7:15 p.m. Unable to move legs. Nods head that legs feel numb.

7:30 p.m. Increased bruising on left side of face and left ear with edema. Crepitus present on nose.

8:10 p.m. Patient cried out “Help me; I hurt so bad I want to die.”

8:50 p.m. Mouth, catheter, and back care done. Log rolled from side to side using three persons. Abdominal...