Cerebral palsy birth injuries medical chart review and case evaluation

Cerebral Palsy Birth InjuriesMedical Chart Review and Case Evaluation Medical chart review and case evaluation is very significant to establish causation that can link a cerebral palsy birth injury to the damages claimed.

Medical Record Review

Cerebral palsy birth injuries are mainly caused due to oxygen deprivation that may stem from a number of reasons that may not be related to medical negligence. Oxygen deprivation during delivery can be avoided and there are specific standards of care prescribed to avoid this issue.

In a case that came to court in early May, a mother testified against the delivering physician, alleging that he did not have a proper plan in place when her newborn baby was diagnosed with hypoxic ischaemic encephalopathy (hypoxia). This led to her son being born with what she claims was a preventable case of cerebral palsy. The woman suffered a ruptured uterus and therefore the attending physician decided to proceed via an emergency cesarean section.

During delivery the child’s heart rate became dangerously slow, which according to the mother was due to lack of oxygen. The doctor administered anti-seizure medication to the baby. It was later noticed that the child was not given cooling or hypothermic treatment that is considered effective to remedy the effects of oxygen deprivation during the birthing process. The evidence showed that the delivering physician did consider cooling therapy for the baby but determined that the child did not meet the criteria for using it. This incident occurred in 2012 and the child has been diagnosed with and still suffers from cerebral palsy.

Medical Records Instrumental during Case Evaluation and Litigation In a medical malpractice claim alleging medical negligence as the cause of a cerebral palsy birth injury, a careful evaluation of the medical records becomes inevitable. The first step in medical litigation involving this type of injury would be collecting all the relevant medical records. If a child has a birth injury, it is the onus of the parents to have a copy of the child’s medical records because after a designated period of time the physicians may not maintain them.

Medical records document diagnosis and are therefore very valuable. When there is an evident physical injury to the baby, it can be diagnosed at the time of birth itself and documented.

However, when there is no obvious physical injury, the diagnosis may comprise a process in which first other conditions have to be ruled out. Birth injuries that cause developmental delays and other issues can be diagnosed only through comprehensive review of the medical history information and test results over a certain period of time. This highlights the importance of maintaining each and every piece of documentation.

Medical documentation of their patients is important for treating clinicians also because these records will help in their defense. If care has been provided appropriately and accurately documented, the medical records on review would prove that there has been no departure from the standard of care during the labor period. This in turn would establish there is no causation that could link the cerebral palsy birth injury of a child to the damages claimed. In such a case, both the mother’s and child’s medical records may be reviewed for evidence.

Medical malpractice attorneys would be looking for proof such as the following:

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Whether the child’s records show any predictors of cerebral palsy during the neonatal period.

Whether there is evidence of fetal distress during the labor Whether there is evidence of peri-natal (the period around the delivery)asphyxia Whether the child displayed clinical signs of asphyxia at birth Whether the mother experienced hypotension or a drop in blood pressure during the cesarean section

Medical evidence such as the above can be mined only by a review team familiar with medical terminology and facts, and experienced in identifying such important information. In a case involving a birth injury such as cerebral palsy, the records are best reviewed by a team comprising medical experts in obstetrics and gynecology, pediatrics and anesthesiology.

Medical Records that Are Required for Evaluation    

Pre-natal care records and other medical and hospital records related to the pregnancy Records related to the labor process and fetal monitoring that will be used to find out the stress levels of the baby during labor and delivery.

The mother’s medical history All the medical records of the baby including the neonatal intensive care unit (NICU) records, post hospital care, and follow-up care records.

In the United States, the law of negligence governs most injuries and accidents and allows innocent victims to seek compensation for injuries caused by the negligent conduct of another.

Medical negligence is also governed by the dame law. Physicians are required to provide their patients with the proper level of care and the patient’s healthcare records comprise the great body of evidence that can save or harm their reputation.

www.mosmedicalrecordreview.com

1-800-670-2809