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This is a 4 Page Hospital Medical Records Summary Sample:

 

DOLORES LARIOS VS. NORTH MIAMI MEDICAL SQUARE
 

SUMMARY OF MEDICAL RECORDS RECEIVED FROM
NORTH MIAMI HOSPITAL


  MEDICAL TREATMENT PRIOR TO SUBJECT INCIDENT
DATE

DESCRIPTION

1/5/99 EMERGENCY ROOM - Mrs. Larios indicates that she is in extreme pain and Percocet does not help. Therefore, she wants an injection for her migraine. (Treatment was authorized by Dr. Ray Miller.)
 
4/6/99 EMERGENCY ROOM - Mrs. Larios is once again in the hospital for a migraine together with vomiting. She indicates that she took Percocet, Premarin and is also taking Estrogen. She was given an injection for her migraine. (Treatment was authorized by Dr. Victor Barr.)
 
6/14/99 EMERGENCY ROOM - Mrs. Larios is once again at the hospital with a migraine and is given an injection for pain. On this date she also indicates to the nurse that she has a history of migraine headaches and had been diagnosed as having a "pinched nerve in her neck." (Treatment authorized by Dr. Ray Miller.)
 
9/5/99 EMERGENCY ROOM - Mrs. Larios is given an injection for her migraine. (Treatment authorized by Dr. James E. Stone.)
 
10/9/99 EMERGENCY ROOM - Mrs. Larios is given an injection for her migraine. She is also complaining of nausea and vomiting together with dizziness, blurred vision in both eyes with sensitivity to light. She took Percocet but vomited it up. (Treatment authorized by Dr. Alan P. Strook.)
 
1/3/00 EMERGENCY ROOM - Mrs. Larios is given an injection for her migraine. (Authorized by Dr. Ray Miller)
 
4/3/00 EMERGENCY ROOM - Mrs. Larios is complaining of abdominal pain. She denies having a history of migraine headaches. She is given Percocet for pain.
 
4/4/00 EMERGENCY ROOM - Mrs. Larios is again complaining of abdominal pain. She indicates that her pain is "radiating to her back." Mrs. Larios is noted to be "hostile and anxious wearing dark glasses." She left the hospital angry and did not wait for medical instructions.
   


 
Summary of North Miami Hospital Records
Page Two

DATE

DESCRIPTION

10/6/00 EMERGENCY ROOM - Mrs. Larios indicates that she has had a migraine for two days. She states that the Percocet was ineffective due to the vomiting. She is very agitated and uncooperative with the nurse. She was given an injection for her pain. (Authorized by Dr. Ray Miller)
 
12/8/00 EMERGENCY ROOM - Mrs. Larios is given an injection for her migraine. (Authorized by Dr. Ray Miller)
 
12/5/00 EMERGENCY ROOM - Mrs. Larios complains of having a migraine for four days together with nausea and vomiting. She indicates that she takes Percocet as needed and Estrogen on a daily basis. She is wearing sunglasses. She has just been to see Dr. Ray Miller. She is given an injection for pain.
 
1/28/01 EMERGENCY ROOM - Mrs. Larios is given an injection for her migraine which she states that she has had for two days for which she has taken Percocet.. She also complains of nausea and vomiting. She is also given a prescription for Percocet for pain.
 
2/6/01 EMERGENCY ROOM - Mrs. Larios is complaining of migraine headache, nausea and vomiting since yesterday. She is given an injection for pain and Percocet for home. She indicates that pain is not responding to Percocet. She tells the nurse to call her EX-HUSBAND for a ride home.
 
9/21/01 EMERGENCY ROOM - Mrs. Larios (now designated as "Medically Disabled since 1990 in the hospital records) complains of migraine, nausea and photophobia at this time. She indicates that she took Percocet. She is given an injection for her pain.
 
10/3/01 EMERGENCY ROOM - Mrs. Larios complains of severe migraine, vomiting and nausea since morning. She had taken Percocet and Phenergan suppositories in the morning with no relief. The nurse indicates that Mrs. Larios "was holding on to ARNP Hardwood to see." She was then given an injection for her pain. The treating physician at the hospital diagnosed her as having Acute Cephalgia.
   

 

Summary of North Miami Hospital Records
Page Three

  MEDICAL TREATMENT SUBachelor of ScienceEQUENT TO SUBJECT INCIDENT
DATE

DESCRIPTION

11/29/01 DATE OF SUBJECT INCIDENT - Mrs. Larios arrives at the hospital Emergency Room at 6:28 p.m. by herself complaining of pain in her shoulder down her arm to her hand. She indicated to the nurse that Dr. Miller had placed a right thumb Velcro splint at his office and had sent her to the Emergency Room. She further indicated that she had fallen within the past hour in an elevator outside Dr. Miller's office and had struck her head on the wall. She braced herself with her right arm. At 7:30 p.m. she started complaining of pain in her wrist, arm, elbow and head. A sling was applied to her right arm. X-rays were taken which showed no fractures. (NOTE: We did not receive Dr. Miller's report of Mrs. Larios's visit to his office on this date.)
 
12/27/01 EMERGENCY ROOM - Mrs. Larios is complaining of headache and nausea. She also has pain in her right knee because she "twisted her leg getting out of the shower prior to coming to the hospital." She indicates that she had taken Percocet for her pain. She was then given an injection and Percocet. X-rays taken of the right knee indicated fairly extensive osteoarthritic changes with squaring of the femoral condyles and osteophytes at the margins. Similar changes were noted on the tibial side of the joint. Prominent osteophytes were noted at the articular markings of the patella. However, no acute fractures or joint effusion was noted.
 
2/13/02 EMERGENCY ROOM - Mrs. Larios complains of migraine headache since the day before with nausea, vomiting and photophobia. She was given her injection and Percocet.
 
3/25/02 EMERGENCY ROOM - Mrs. Larios complains of migraine headache since the day before with nausea. She took Percocet for pain. She is wearing sunglasses for photophobia. She was given an injection for her pain and Percocet.
 
3/27/02 EMERGENCY ROOM - Mrs. Larios complains of severe headache with nausea, vomiting and photophobia. She is raising her voice stating that "she is in pain and is to be seen right away by Dr. Miller's orders." (She was seen by Dr. Miller that day.) Her right eye has a patch on it for she had surgery recently. Her injection was given.
 
4/29/02 EMERGENCY ROOM - Mrs. Larios complains of migraine associated with photophobia and states she had vomited two times prior to coming to the hospital. She indicated that she ran out of Percocet at home. An injection was given for her pain. The doctor's notes indicate that Mrs. Larios requested a prescription for Percocet #12.
   

 

 

Summary of North Miami Hospital Records
Page Four

DATE

DESCRIPTION

7/23/02 EMERGENCY ROOM - Mrs. Larios complains of severe migraine, nausea and right eye pain. She states she had right eye cataracts and had implants on 7/2l/95. Drainage is noted on her right eye. She indicates that she was sent in to the hospital by Dr. Miller for narcotics injection. She was given her injection and Percocet (#10) for pain.
 
8/16/02 ADMISSION TO HOSPITAL - Mrs. Larios is admitted to North Miami Hospital by her treating physician, HARVEY BRAMAN, M.D. , for a torn meniscus of the right knee. In her medical history she indicates that she is taking Percocet and Progestins. Dr. Braman indicates that Mrs. Larios "fell on a wet floor on November 29, 2001 "striking the back of the elevator with her entire right side including her right knee." He initially saw her on December 6, 1994. (NOTE: We do not have those records.)
 
  HISTORY: Dr. Braman indicates that Mrs. Larios's past history includes a torn cartilage of her right knee operated in 1997 or 1998. (Prior to subject incident.) He further indicates that she was treated with anti-inflammatory agents, orthosis and therapy without much relief. She complained of her knee "giving out, felt unstable, intermittent swelling and pain..." He is, therefore, admitting her to the hospital for arthroscopic surgery.
 
  PREOPERATIVE DIAGNOSIS: Internal derangement of the right knee together with chondromalacia of the patella femoral joint.
  POSTOPERATIVE DIAGNOSIS:

l. Internal derangement of the right knee
2. Chondromalacia of the patella femoral joint.
3. Chondromalacia of the medial and femoral condyle and flap tear lateral meniscus, and synovitis
 

10/17/02 EMERGENCY ROOM: Mrs. Larios came to the hospital complaining of migraine, possible Urinary Tract Infection and pain in her right flank. An injection was given to her for her pain. She was given a prescription for Percocet and Macrobid.

 


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