September-October 2012

Medical records or alphabet soup?

K. Sunshine Stanek

Assistant District Attorney in Lubbock County

Kim Elliott

Investigator in Lubbock County

A clip-and-save guide for deciphering jargon and abbreviations from medical records

In preparing for trial, have you ever sat down with mountains of medical and EMS records and dreaded deciphering not only the handwriting but the medical terminology in them?

    In getting ready for a recent murder trial we did not fully appreciate the wealth of information contained in the records until we sat down with the paramedics who were first on scene.

    The facts, in short, were as follows: After stabbing three people, the defendant was transported by EMS for a visible injury to his hand and complaints of a head injury. In a subsequent statement to detectives, the defendant said he did not remember anything after arriving at the victim’s house to watch a football game. The first thing he said he remembered was waking up in the hospital. However, the EMS patient assessment report told a much different story.

    The defendant told medics he was acting in self defense and his “CC” was pain in his head and hands. He indicated that the only “MOI” he remembered was a blow to his head with a baseball bat. During transport, Medics saw no “S&S” of a head injury, but they documented “superficial lacs” in the webbing of his “rt” hand with minimal bleeding. This injury, we found out later, was caused by the murder weapon slipping while the defendant stabbed his victims.

    In addition, the EMS records reflected “No LOC, PERL, and CAOX3”—that is, that he had not lost consciousness, his pupils were equal and reactive to light, and he was conscious, alert, and oriented to 1) person, 2) time, and 3) place. These observations, as explained by the paramedics, quite obviously contradicted the defendant’s claim of a head injury.

    Not only were we able to use the medical records in our case to prove the elements of the crime, but we were also successfully able to discredit the defendant’s story of what had happened at the scene. He testified at trial and was flustered to no end when confronted with the records. Even after sitting through the testimony of the paramedics, he was unable to conform his version of events to reflect what was contained in the paramedics’ report. The defense argued self-defense, but ultimately the jury convicted him of capital murder.

    In Lubbock County, we have the luxury of an investigator on staff, Kim Elliott, who is also a certified EMT. But without her and/or our local paramedics explaining their occupational jargon, we would be at a loss trying to decipher medical records in preparation for trial—hospital records are instrumental in the successful prosecution of many types of cases. (Remember to obtain not only your defendant and victim’s hospital records, but their EMS records as well, if applicable.)

    Kim put together the cheat sheet on page 44 to assist other investigators and prosecutors in understanding common medical terms and their abbreviations on medical records. It is useful in an initial review of the records, but do follow up with those who wrote the reports for further and contextual explanation, as this is not a comprehensive list of abbreviations but rather those we have seen most frequently. In addition, the following websites are also helpful and were used in compiling the attached information:

• patients/glossary.php
• main/art.asp?articlekey=9210
• Approved-Medical-EMS-Abbreviations.

(See the PDF attachment, below, for the common medical abbreviations and common medical terminology.)