Medical Records
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?…
Read MoreEmergency Department Medical Records Part 1
Use your legal nurse consulting skills to help attorneys understand emergency department medical records. Here are some of the details in emergency department medical records that affect personal injury cases. Analyzing emergency department medical records • Who first saw the patient? Usually a triage nurse will evaluate the patient before the patient is officially checked…
Read MorePersonal 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…
Read MoreMissing 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…
Read More3 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…
Read MoreWhy I like Paper Medical Records
Sometimes I feel a little like a dinosaur. I like paper medical records. I like them printed out, organized and ready for my review as a legal nurse consultant. Medical record review: which is faster? Although I received PDFs of medical records, I used them to print out paper records. Using preprinted medical record tabs,…
Read MoreComputer 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…
Read MoreComputer Provider Order Entry: Saving Lives and Money Part 1
Legal nurse consultants increasingly receive electronic health records (EHRs) for analysis. How do EHRs save money and lives? What specifically are the advantages of computer provider order entry? 1. Computer provider order entry saves money Having a provider (physician, nurse practitioner or physicians assistant use a computer to enter medication orders saves money. Drug-related errors…
Read MoreMissing Documentation
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…
Read MoreIs 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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