Emergency Department Medical Records Part 2

Legal nurse consultants play a vital role in helping attorneys understand medical records. Here are some of the things you may find in emergency department medical records. Read part 1 for more tips about emergency department medical records. What to look for in emergency department medical records • Was there a positive alcohol smell noted?…

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Personal Injury Medical Records – What to Look For

Physician office records may hold the keys for analyzing personal injury cases. These personal injury medical records can make or break a plaintiff’s case. It is crucial that you as the legal nurse consultant are able to read and decipher these records in a personal injury case. Look for these pieces of information. Personal Injury…

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Missing Medical Records

How do you know as a legal nurse consultant that there are missing medical records? Are the medical records complete? Although a copy of a certified medical record is supposed to be compared by the medical records custodian with the original, it is common for LNCs to detect there are missing medical records. This often…

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3 Ways to Pitch Your Value to Attorneys: Medical Records

Anyone can read a medical record. Or can they? If everyone could read medical records, the attorney would not need someone with medical background to assist in understanding the medical records. How do you pitch your value to attorneys about medical record analysis? This is what an LNC offers: the keys to medical record analysis…

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Computer Provider Order Entry Part 2

Legal nurse consultants are increasingly receiving electronic health records for analysis. How do these records help patients and providers? How does computer provider order entry affect medical care? In part 1, I specifically addressed the savings of computer provider order entry.  1. Facilities using EHRs and computer provider order entry could gain greater market share…

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Missing Documentation

missing medical records

Legal nurse consultants receive medical records from healthcare providers, either through working as an employee in a law firm, insurance company or being an independent consultant. If we want full certified records we trust that the facility will send them. The attorney relies on us to recognize if there is missing documentation. We don’t always…

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Is it Substandard Charting or Fraudulent Charting? Part 2

In Part 1, I explained how you can spot substandard charting. Suspicious charting goes one step further to raise concern about the medical records. Substandard Charting or Fraudulent Charting Trouble: Detailed addenda Healthcare providers may feel compelled to write detailed addenda to the medical record after they learned a patient was injured or was considering…

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Is it Substandard Charting or Fraudulent Charting? Part 1

The attorney tells you she has a suspicion that the medical record has fraudulent charting. She thinks the medical documentation of healthcare providers may be incomplete, untimely, illegible, or incorrect. You know that substandard documentation may itself result in an untoward outcome for the patient and thus factor into a medical negligence suit. However, what…

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Tampering with Medical Records

Red Flags for Tampering with Medical Records What are the red flag warning signs that someone may have been tampering with medical records? Be suspicious when: the result of the injury is not consistent with the documentation; the plaintiff’s complaints are consistent with the missing information; there is a delay in or an inability to…

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