XXXX XXXX - Trivent Legal

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|MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW |
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|General Instructions: |
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|Brief Summary/Flow of Events: |
|In the beginning of the chronology, a Brief Summary/Flow of Events |
|outlining the significant medical events is provided which will give a |
|general picture of the focus points in the case |
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|Patient History: |
|Details related to the patient's past history (medical, surgical, social |
|and family history) present in the medical records |
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|Detailed Medical Chronology: |
|Information captured "as it is" in the medical records without alteration |
|of the meaning. Type of information capture (all details/zoom-out model |
|and relevant details/zoom-in model) is as per the demands of the case |
|which will be elaborated under the 'Specific Instructions' |
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|Reviewer's Comments: |
|Comments on contradicting information and misinterpretations in the |
|medical records, illegible handwritten notes, missing records, |
|clarifications needed etc. are given in italics and red font color and |
|will appear as * Reviewer's Comment |
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|Illegible Dates: Illegible and missing dates are presented as |
|"00/00/0000"(mm/dd/yyyy format) |
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|Illegible Notes: Illegible handwritten notes are left as a blank space |
|"_____" with a note as "Illegible Notes" in the heading of the particular |
|consultation/report. |
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|Specific Instructions: |
|Medical chronology focuses on the fall injury on 03/05/YYYY, the resulting|
|injuries and their treatment |
|The chronology has been prepared adhering to your instructions and the |
|work plan that we shared. We have not included any records pertaining to |
|injury prior to the accident. We have chronologically arranged the events |
|in the medical chronology and provided the date of the visit, the |
|provider's name, impressions/ assessments and plan. Details pertaining to |
|liability/causation have not been included |
|The other related documents in hospitalization records such as labs are |
|combined under the heading of related documents in the hospitalization. |
|Police Report/Accident Scene Investigation Report/ Emergency Medical |
|Service are unavailable hence the tabulation is not included in the |
|chronology. |
|Detailed description of initial and final Physical Therapy/ Occupational |
|Therapy visits is provided. Interim visits are summarized. |
|Case specific details have been highlighted in yellow for easy reference. |
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|A snap shot of the provider is given when the provider's name is |
|illegible. | Brief Summary/Flow of Events ABC Hospital
03/05/YYYY - 04/07/YYYY: Fall injury, unresponsive at scene - Hospitalized
and intubated - Underwent ventricular drain placement, intracranial
pressure monitor and left frontal oxygen sensor and placement of lumbar
drain - Diagnosed with traumatic brain injury, basilar skull fracture,
right frontal subdural hematoma and pulmonary contusions - Discharged on
04/07/YYYY and referred to Neurosurgery, Physical, Occupational and Speech
Therapy
[pic]
ABC Hospital
04/08/YYYY: Complained of headache - Recommended to use Acetaminophen or
Ibuprofen or Naproxen and to increase hydration
[pic]
XXXXX, M.D.
04/17/YYYY: Hearing issues in right ear and cracked teeth - Will make
appropriate referral
[pic]
ABC Hospital
04/22/YYYY: Little bit of imbalance on tandem gait - Recommended rehab on
an outpatient basis
[pic]
XYZ Ear Nose and Throat Hospital
05/08/YYYY: Decreased hearing right - Diagnosed with mixed conductive
hearing loss of both ears, hypertrophied nasal turbinates and subjective
tinnitus - Start Fluticaone, nasal steroid and nasal saline gel - Ordered
for CT temporal bone
[pic]
ABC Hospital
05/04/YYYY - 06/11/YYYY: Underwent Occupational Therapy for traumatic brain
injury and multiple skull fractures with CSF leak with some improvement
[pic]
XXX, M.D. F.A.C.S.
08/24/YYYY: Right hearing loss - Diagnosed with right conductive hearing
loss secondary to his head injury - Recommended to undergo right
tympanoplasty with possible ossicular reconstruction and ordered for CT
scan
[pic]
ABC Hospital
05/04/YYYY - 09/25/YYYY: Underwent Physical Therapy for traumatic brain
injury and multiple skull fractures with CSF leak with some improvement
[pic]
XYZ Hospital and Medical Center
10/12/YYYY: Right conductive hearing loss - Scheduled for Right
tympanoplasty with ossicular chain reconstruction
[pic]
ABC Otolaryngology Consultants, P.C
12/11/YYYY: Tympanic membrane well healed - Return in two months
Missing Medical Records |What |Hospital/ |Date/Time Period |Why we |
|Records |Medical | |need the |
|are |Provider | |records? |
|Needed | | | |
| | |Fall injury on 03/05/YYYY | |
|03/05/YYY|ABC School |Incident report for fall injury: |1 |
|Y | |Description of incident: A student opened the rear | |
| |Provider |Emergency exit door and jumped out of the bus while | |
| |unavailable|the bus was travelling approximately 20 mph. The | |
| | |student hit his head on the pavement and required | |
| | |medical assistance. Took place on Bus #14. | |
| | | | |
| | |Description of immediate actions: The driver called | |
| | |911 and emergency personnel were notified. I | |
| | |travelled to the scene with a member of the | |
| | |maintenance staff. | |
| | | | |
| | |List of people involved/affected: Patient, bus driver| |
| | |and bus aide | |
| | | | |
| | |List people notified: 911, Elyse Moya, Dr. XXXX and | |
| | |XXXX | |
|03/05/YYY|ABC |Admission history and physical for fall injury: |344-347, |
|Y |Hospital |Chief complaint: Trauma, head injury, Altered Level |116-119 |
| | |of Consciousness (ALOC). | |
| |XXXX, M.D. | | |
| | |History of present illness: Approximately 10 year old| |
| | |boy, presents as level 1 trauma. EMS reports that | |
| | |patient was in a school bus this morning, when | |
| | |patient jumped or fell out of the bus while it was | |
| | |moving at approximately 25 mph. Reportedly patient | |
| | |rolled several times on the ground and was | |
| | |unconscious. The bus driver stopped the bus and ran | |
| | |back to the patient where he was found to be |