MEDICAL RECORDS REVIEW
Customer Name
ATTORNEY: Attorney Name
By C.W. de Boisblanc
Health Information Search, Inc.
#XXXX.SYN; Date here  

SUMMARY
The patient had decompression laminectomy on Date after presenting with neurogenic claudication to Dr. Doctor Name , orthopedics. At the time admit orders were written, the surgeon wrote for an prescription dose. The holding Preoperative Assessment records indicate that PX was given at dose,but this conflicts with the charted account of the patient having been transferred to the OR at timepm. The procedure included L4, L5 with a partial facetectomy and foraminotomy bilaterally. The procedure was normal and resulted in a 100cc EBL. He was discharged the following day. DC instructions on date included to contact the doctor if temp >101.0F; pain not relieved by meds; bleeding from incisional site; no other instructions. Anecdotal information from the patient indicates that he had the first postop visit the surgeon on date at which time the staples were removed and there appeared to be no inflammation at that point.
On date, the patient called Dr.Name and stated that since the removal of the staples, he had experienced increased pain, including significant soreness and tenderness of the incision. The patient also experienced shaking chills. The surgeon advised the patient not to worry and to keep his scheduled appointment five days hence, date. . On presentation to the doctor on that date, he was advised to go right to the hospital, as there was a serious infection. The incision was opened under GA and an abscess was drained. He was D/C home on 1/3/98.

COMMENTARY
The use of antibiotic intraoperatively is a good practice but not considered standard. However, in this case, the surgeon did believe it was appropriate and gave orders for prescription dose to be given IM. This was done before surgery but about 25 minutes earlier than that recommended, based on the 1999 PDR, but not in 1997 PDR. The patient should have been told to come to the doctor’s office, as there should have been no increase in pain especially at the incision site after three weeks. Defense will argue that three days would not have made any difference. Further, that had the doctor seen the patient on date the patient may not have manifested other signs and symptoms of an inflammatory process, such as increased HR, R, and fever, at that point.  It also may be hard to prove that admittance to a hospital on date would have resulted in less total hospital time. This would seem to be a difficult case to win in court but might be settled on the basis of the doctor failing to agree to see the patient or for not referring him to a ER.