By Maya Siobhan Redding | Jul 5, 2018

Electronic medical records are a challenging component for attorneys who are not trained in understanding the intricacies of these documents. 

Being able to decipher and accurately extract information from these files is crucial to the support of attorneys determining their involvement in a case. 

During the 2018 Florida Justice Association convention June 19-22 in West Palm Beach,  Georgia-based medical consulting business GR Consultants stationed their booth in the convention hall along with three other medical consulting companies including Tanner Legal Nurse Consulting, Record Reform and Kung Consulting. 

“Most of us have come from an ER background. We take all the medical records and tell the attorney what they have and teach them the medicine behind the scenes. Then, if they actually have a case, we find the experts to testify in court and then we do all the medical research.” Gyalia Rutledge, a nurse, legal nurse consultant (LNC) and president and owner of GR Consultants, said. 

The role of an LNC is to demystify the medical records for the attorney. The combination of medical knowledge along with understanding the law is a valuable asset and saves attorneys thousands of dollars and a lot of time and hassle when they’re advised by medical consultants whether or not case is not worth taking. 

Consultants are also able to identify missing records. An attorney may think they have the medical records from the University from Miami, for example, when in actuality they have the discharge instructions from the emergency room and perhaps they’re missing the MRI or the urine drug screen. 

Rutledge shared an example of a personal injury case she contributed to where she validated the extent of a plaintiff’s injuries in a situation where it was being fabricated in efforts to get him into a particular rehabilitation center. 

“The gentleman runs his little BMW underneath a semi," Rutledge said. "He survives; breaks every bone from the waist down and crushes him from the pelvis down. He was put into a medically induced coma to allow his body to heal from the waist down. He did not have a head injury; he had a scalp laceration. So in other words, there was no trauma to the brain. It basically scalped him but left his scull intact.  

"When they discharged him from the hospital, the discharge summary stated scalp laceration," Rutledge said. "But because they wanted to send him to Sheppard Spine Center in Atlanta for intense rehab, his case manager for workman’s comp put a diagnosis of closed head injury and spinal cord injury. She literally just changed the diagnosis so the Sheppard Spine Center would take him. Out of 3,500 pages of medical records, it came down to two pieces of paper; damages: scalp laceration vs. closed head injury. 

"He was discharged with a scalp laceration but the admission history physical said closed head injury," Rutledge said. "The other attorney was saying ‘you have got a closed head injury and y’all need to pay for this’ and we were like ‘no, we don’t.’ We won. 

"It came down to me knowing what those two pieces of paper were amongst thousands of pages of medical records. I could take him to the page. I literally create reports that tell the attorney on page 5,742 is your lab report. On page 2,347 is your radiology report," Rutledge said. 

Examining past medical records plays a role in determining the factors that may or may not have influenced an injury. A person may have had an injury three years prior in which they received medical attention, went to rehab and resumed their lives without any issues. This person then has an accident and medical consults look at whether it’s the same problem they had before and it’s just been exasperated or if it’s a different type of injury. Through medical records and with their expert testimonies, consults discern whether or not it was related to the previous injury. 

Although there are attorneys who have been in practice for years and feel comfortable with medical records, Sandra Krug, founder and coordinator of Krug Consulting, says that considering all of the changes with electronic medical records, all of that is out the door now. 

“When you go and try to get medical records for cases, you’ll get thousands of pages printed out with a lot of repeated information and information that doesn’t really tell you what was going on with the patient at the time," Krug said. "What we’re required to do in electronic medical records now is all of these drop down boxes and things that you have to do and check. There’s not a lot of free typing in there to really explain what was going on. It’s very hard to get that information. The attorneys really need health care experts to go in there and help them review that.”

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