Medical Records
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…
Read MoreAltering Medical Records Consequences
Legal nurse consultants may detect tampering with medical records. What happens to healthcare providers who get caught? What are the altering medical records consequences? Shame and embarrassment Loss of reputation, shame, guilt, and being exposed as a wrong doer can all have a profound impact on the individual who altered medical records. It is terribly…
Read MoreTampering 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…
Read MoreThe Medical Records Arrived: What Do You Really Have?
The medical records arrived and it is time to evaluate what type of files you actually received. Electronic medical records or EMRs describe anything from paper records being scanned into a PDF format to an actual EMR. The records can also be a combination of scanned records and computer generated EMR information. True EMRs are…
Read MoreLegal Nurse Consultants: What I Learned from Handling Volumes of Cases (Part Two)
Legal nurse consultants: did you know volumes of cases can radically change your business? I did not know what was ahead of me when I received a call from a defense attorney who approached me to assist his firm and client defend a series of claims involving an orthopedic device. In Part One I described…
Read MoreLegal Nurse Consultants: What I Learned from Handling Volumes of Cases (Part One)
Volumes of legal nurse consulting cases can radically change your business. I did not know what was ahead of me when I received a call from a defense attorney who approached me to assist his firm and client defend a series of claims involving an orthopedic device. He was handling dozens of cases which had…
Read MoreLegal Nurse Consultants: 4 Medical Record Analysis Barriers
What are the 4 most common medical record analysis barriers you will encounter as a legal nurse consultant? Disorganized medical records The records come into your possession in no particular order. They were scanned and saved to a disk before they were organized, which requires you to sift through them to rearrange pages. You may…
Read MoreTop 10 Hints for Medical Records Management
Legal nurse consultants are often involved in medical records management. Here are some tips to make the job of organizing medical records go more smoothly. 1. Let the attorney know if you need a certified medical record or an abstract. A medical malpractice case involving a specific admission would be difficult to evaluate without a…
Read MoreWhy Medical Records can be Defective
Medical records can be defective. We know that as legal nurse consultants. The analysis of cases involving medical issues rests heavily on being able to extract meaningful information from medical records. Why are some electronic medical records inherently defective? Medical record software program defects One reason why medical records can be defective is an inadequate…
Read More“If you didn’t chart it, you didn’t do it” Part 3: The Nursing Home Defense Perspective
Do you subscribe to “If you didn’t chart it you didn’t do it”? Incomplete nursing records plague all types of settings and complicate nursing home defense strategies. Nursing homes are particularly vulnerable due to the low number of professional staff available to document. Nursing homes have many challenges, many of which directly affect the quality…
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