Surgical Errors & Wrong-site Surgery Injury Lawyers

Key Records We Secure Early:

1. Operative Reports and Notes are detailed documentation prepared by the surgeon immediately following a surgical procedure. These reports include the preoperative diagnosis, the surgical procedure performed, findings during surgery, techniques used, any complications encountered, and the condition of the patient at the end of the procedure. They serve as a critical legal and medical record for treatment verification and case evaluation.

2. Anesthesia Reports are records maintained by the anesthesiologist outlining the type and dosage of anesthesia administered, patient’s vital signs throughout the procedure, monitoring details, any anesthesia-related complications, and the patient’s status upon emergence from anesthesia. These reports are essential for documenting the anesthetic care and identifying potential causes of injury or malpractice.

3. Intra-operation Nursing Notes are notes taken by the circulating and scrub nurses during surgery detailing patient positioning, surgical site preparation, intra-operative care provided, observations, and any issues arising during the procedure. They help verify adherence to protocols and provide a timeline of intra-operative events.

4. Surgical Tool & Sponge Count Sheets are checklists documenting the number of surgical instruments, sponges, and other materials before, during, and after surgery. Accurate counts ensure no foreign objects remain in the patient postoperatively and prevent complications. These records are critical in cases alleging retained surgical items.

5. Implant Logs are comprehensive logs recording the details of any implants used during surgery, including manufacturer, model number, serial number, lot number, and date of implantation. These documents are vital for tracing defective devices and supporting product liability claims.

6. Notes & Report Timestamps are time-stamped entries for all operative documentation, including when notes were recorded, interventions performed, and reports finalized. Accurate timestamps establish chronological order and authenticity of medical records, which are crucial in legal proceedings.

7. Device IFUs (Instructions for Use) are manufacturer-provided documentation that outlines the appropriate usage, maintenance, safety warnings, and contraindications for medical devices and surgical implants. Retaining IFUs aids in evaluating compliance with standards and device-related liability issues.

8. Pathology Reports are laboratory results and expert analysis of tissue samples obtained during surgery. These reports detail diagnoses such as malignancies, infections, or other pathological findings that influence treatment and prognosis. Pathology documentation can clarify causal relationships in injury cases.

9. Adverse Event Reports are formal records describing unexpected or harmful incidents occurring during or following surgery, including complications, equipment failures, or patient injuries. These reports are used to investigate the cause of adverse outcomes and support claims of negligence or malpractice.

10. PACU (Post-Anesthesia Care Unit) Notes are records from the recovery room documenting the patient’s vital signs, pain management, responsiveness, and any immediate postoperative complications observed. PACU notes provide insight into the patient’s condition following surgery and are important for assessing the standard of postoperative care.