Torts: Auto Accident and Personal Injury, assignment help

Question Description

One of your firm’s clients is John Q. Doe and his wife Jane. John was injured in an automobile accident and is currently in a coma. The firm is preparing to sue the driver of the other car if a settlement cannot be reached with the driver’s insurance company.

Your supervising attorney hands you medical records he just received and asked you to prepare a medical records summary and a short one page memo addressing any particularly helpful or harmful information you discover in your review.

John Doe Medical Records

Medical Record Template

Use the Excel template for the medical records summary. Note that the MS Word document is not as lengthy or complete as a regular medical record, which is to avoid creating too much “quantity work” for you in the assignment. Your completed Excel template should show the oldest information on the top and be in chronological order from top to bottom, not like the information supplied to you.

Unformatted Attachment Preview

John Doe Medical record. Bennett Mental Health Clinic: 2.28.15. Follow up appointment at the clinic. Dr. Bennett and Ralph Kalder, MSW worked with John Doe and his family. They convinced Doe that Jane Doe was his wife, but he did not feel safe returning home, since he does not remember them. The family was able to work through the feelings this engendered, but without coming to a resolution. Ralph assisted John in obtaining temporary housing, finding volunteer activities and a counselor. Hospital: 2.27.15 Ralph Kalder, MSW, visited Doe and it was determined that Doe could not return home, although he is discharged from the hospital. Doe was placed in assisted living and will have a clinic visit with Kalder and Dr. Bennett. 2.27.15 Dr. Reynolds. John Doe has revived and appears to be oriented as to location. He knows who he is, but has “lost the last 15 years, so does not know his wife or young children. He is mobile, but will need assistance in reconnecting with family and friends. His prognosis is that he will have significant long term memory loss, and will appear to his family and friends to have “amnesia” but he will be able to perform all bodily functions on his own and will gradually regain some, but not all, of his memory functions (memories of new events.) Psychiatric and Social Work assistance will be needed prior to discharge. 1.26.15 Dr. Reynolds John Doe has been taken off all medications and needs to be watched constantly to determine if the surgeries were successful. 1.24.15 Nurse Notes. John Doe has been moved to Room 503B. John Doe remains in an induced coma. 1.22.15 Doctor Foshager’s dictation. Doe survived a second surgery, but it is not medically indicated at this time to end the coma. Dr. Foshager referred the case to Dr. Reynolds for all after care. 1.21.15 Second Brain surgery. Dr. Foshager performed surgery on the area of the trauma and then induced a coma, pending reduction of the swelling. Dr. Foshager indicated that the first surgery, done by Dr. Jones was not done in the correct area of the brain. Additional damage was done to the memory section of the brain. It was not clear to Dr. Foshager how much damage was done by the auto accident, and how much by the first surgery. 1.20.15 Doe has not recovered and is still not responding well. Dr. Jones indicated in notes that the brain surgery stabilized the patient, but was not successful. 1.05.15 Surgery to reduce brain swelling by Dr. Jones. Dr. Jones reported some success, but did not achieve complete success. Dr. Jones failed to notify this facility that he is no longer board certified in Neurosurgery. He has been removed from any hospital privileges as a result. The patient’s wife was not happy with either this hospital or Dr. Jones and the case has been transferred to Dr. Foshager. 1.04.15 11: 50 PM. John Doe taken to emergency room after a severe auto accident. Doe was unconscious and bleeding and needed transfusions. There was severe head trauma. Dr. Kyle, Emergency Physician, worked with Doe in the emergency room and after stabilizing Doe, Doe was referred to a Neurosurgeon, Dr. Jones. Patient: Date of Service Dr./Faciity Type of Record Chart Entry Comments & Follow-up .

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