John Jackson Consulting

Analysis of medical records in expert reporting

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The Problem
It is frequently the case that medical records are provided from the general practitioner, several hospitals and possibly occupational health records as well. Those from the GP may contain four types of document, (i) the ‘Lloyd George’ cards, (ii)computerized medical records, (iii) correspondence and (iv) reports of the results of investigations and tests. Individual documents in each type are often in date order. The other types of record are also likely to be in date order. It is not uncommon for there to be seven or more types of document, each type in approximate date order sequence.  A system is needed to integrate these into a single secular sequence.

Method of documenting the medical history from the notes

An assembly of GP and various hospital medical records in a bundle are not in a single chronological order and contain duplicates: letters between GPs and Hospital Consultants are generally found in both GP and Hospital notes. I divide the documents into bundles in a rational fashion that depends on the amount of paper as well as the number of sources. I may use separate bundles to separate papers that are single sided from those that are double sided (to facilitate scanning) or to separate papers in manuscript (that cannot be converted into recognisable text) from typed or printed papers that can be converted to searchable text by Optical Character Recognition (OCR). 

Each bundle is then scanned using a multi-function printer that can scan both sides of a page (black and white) at about 20 pages per minute. After checking for completeness and legibility, the bundles are retained until the report is completed. Scanning automatically paginates the bundle. 

I use a spreadsheet (Fig 1) to record the information in the records. The first row is a record of the date of birth. Working from the scanned documents, each page is inspected to identify material information. In hospital records, there are frequently nursing checklists that do not contain significant clinical information. For each page with information, at row in a spreadsheet is completed for each dated item of information. In the first column the date of the item is entered. The spreadsheet calculates the age of the person on the date and the weekday of the date. This may be important where someone tends to have medical events associated with, for example, the weekend. I enter the Bundle ID and the page in the corresponding columns and the medical information in the item column. The column X is used to record the certainty of a date. A medical note may say something like ‘Headaches since May 2012’ or ‘RTA in 2003’. In these cases, column X would be ‘0’ and the dates would be recorded as 15/5/2012 and 30/6/2003 respectively. Fig 1 shows the first five entries in such a spreadsheet. The entries are sequential in page order. 

Fig 1 
Chronology  Name  
Note: Column X is 1 if the date is precise. Otherwise the value in column X is 0. If only the month is known, the date is shown as 15th of that month and if only the year is known, the date is shown as 30th June that year.
DateXAgeBundlePageItemDay
6/06/194810.0CS1BirthWed
22/04/1999151CS11Referred to dermatology with discoid scaly lesions of buttocks. Dx Erythema annulare centrifugumThur
14/05/1993145CS21Heavy smoker 20 - 39 cigs/day.Fri
09/05/1984136CS46BP 145/90Wed
13/09/1993145CS59Serum triglycerides high at 2.3 (ULN 1-9)Mon
07/01/1992144CS93Pelvis hips and right knee X-rayed. [?RTA]Tue

 
When all the data has been entered, the spreadsheet is sorted into date order and the result is as in Fig 2.

Fig 2 
Chronology  Name  
Note: Column X is 1 if the date is precise. Otherwise the value in column X is 0. If only the month is known, the date is shown as 15th of that month and if only the year is known, the date is shown as 30th June that year.
DateXAgeBundlePageItemDay
16/06/194810.0CS1BirthWed
09/05/1984136CS46BP 145/90Wed
07/01/1992144CS93Pelvis hips and right knee X-rayed. [?RTA]Tue
14/05/1993145CS21Heavy smoker 20 - 39 cigs/day.Fri
13/09/1993145CS59Serum triglycerides high at 2.3 (ULN 1.9)Mon
22/04/1999151CS11, 12Referred to dermatology with discoid scaly lesions of buttocks. Dx Erythema annulare centrifugumThur
 

Where a page is duplicated (e.g., a letter in both the hospital and GP records), the information in the 'Item' column is merged and the page number(s) of duplicates is added in the page column and then the redundant row(s) are deleted.

A further benefit of this method is described in the Expert Witness  3 page.