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Medical Records for Attorneys.

Laurence M. Deutsch American Law Institute-American Bar Association 464 pp., $99

Written by a knowledgeable malpractice attorney, this eminently readable book is a valuable introduction to medical records. Attorneys just entering the medical malpractice arena will find detailed guidance on how to understand hospital charts. The examples of forms included in medical charts and explanations of who fills them out and how are instructive.

Laurence Deutsch writes about how particular medical entries are relevant in malpractice litigation, which is especially helpful to new lawyers. Chapter two explains in considerable detail what should be included in patients' charts. The discussion of how physicians obtain patients' histories and conduct physical exams should prove helpful to new attorneys who may not be familiar with these procedures.

Experienced medical malpractice litigators, however, may find Medical Records for Attorneys of limited value. The book would be more helpful to these readers if it covered not just how to read medical records but also how to analyze them. Detailed chronologies based on records are essential to understanding a patient's treatment and uncovering discrepancies in the chart. Attorneys sometimes find discrepancies by inspecting markings stamped on the records by an addressograph (usually a purple stamped notation of the patient's name, address, and hospital room number in the upper right corner of pages) or comparing chart entries with other documents that hospital staff generate, such as logs of patients in labor and delivery.

For instance, a file may contain a handwritten note dated May 1 that bears an addressograph stamp indicating that the patient was in room 309. But the patient may not have been moved to room 309 until May 20. A labor and delivery logbook may show that an obstetrician was performing a cesarean section on another patient at the same time that a note in your client's chart indicates the obstetrician was in the room with your client. Unfortunately, this book pays scant attention to documents other than the handwritten entries in a patient's records.

The book would also be more useful if it included the checklists that medical records departments use to ensure that charts are complete.

Chapter seven falls short in its coverage of obstetrical records. There, the author notes that a mother and infant have separate charts. He details the mother's record but writes nothing more of the infant's, which is usually the basis of proximate-cause defenses that bedevil birth-trauma plaintiffs.

On the other hand, a few sections that are included in the book detract from its value. For example, part of chapter one covers the psychological tools attorneys need to evaluate contradictory evidence. This seems unnecessary: Even novice attorneys should know from law school, if not TV and movies, that a case may involve contradictory claims supported by conflicting factual testimony.

A section in chapter two theorizes about why emergency-room visits generate a disproportionate share of medical malpractice litigation. Deutsch focuses on several factors: no prior physician-patient relationship, emergency-room patients' lack of sophistication, and their tendency to engage in denial and wishful thinking, which, he says, often leads them to blame physicians for the effects of the illness or accident that brought them to the ER in the first place.

Nowhere does he mention that some patients who are taken to emergency rooms--victims of heart attacks, gunshot wounds, trauma, and respiratory distress--urgently need immediate, lifesaving care. Their precarious medical conditions and the treatment required render them more vulnerable to malpractice. The author ignores this fact.

With some revisions and additions--including references to statutes, regulations, case law, and professional standards for maintaining records--a second edition could be more valuable as a reference tool for all medical negligence practitioners. Until such a revision is published, this text is worthwhile reading for new attorneys who are not familiar with medical records.

Lee Tilson practices law in Southfield, Michigan.
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Copyright 2002, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Tilson, Lee
Article Type:Book Review
Geographic Code:1USA
Date:Apr 1, 2002
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