Medical Records Archives - Page 4 of 5

Nursing malpractice? Death of a 42-year-old

Let’s look at the following situation involving a nursing malpractice case: Facts of a Nursing Malpractice Case A 42-year-old is admitted to an orthopaedic unit after being found in a collapsed abandoned building. He was trapped and pinned under rubble for approximately 27 hours. He sustained a right femur fracture and was also diagnosed with…

“If you didn’t chart it, you didn’t do it” Part 2: The Nursing Home Defense Perspective

Nursing homes are affected by many challenges, many of which directly affect the quality of care and allegations of nursing home negligence. Nursing home defense may center around the documentation. The challenges were highlighted by speakers at Preventing and Defending Long Term Care Litigation at The Conrad in Miami. Pat Iyer moderated a panel of…

8 ways to use electronic monitoring to track nurses and patients

using technology to track nurses and patients

How many ways can we use electronic monitoring to track nurses through technology? Attorneys and legal nurse consultants can tap a number of ways to determine who was doing what at what time. Nurses’ activities can be tracked with the advent of scanned badges, Pmnicell/Pyxis medication machines, telemetry and electronic medical records. Technology can provide…

Electronic Medical Records: How Useful Are They?

Click on the image to enlarge. If you can tell me what it says, I will pat you on the back. Electronic medical records can confuse the analysis of a case. Scenario: Mrs. Smith sustained multiple trauma including a severe brain injury after a fall. She was minimally responsive and had severe contractures of all…

“If you didn’t chart it you didn’t do it.” Part 1

In the medical legal world, “if you didn’t chart it, you didn’t do it” engenders more fear in nurses than almost any other phrase as it is used to reiterate the importance of documentation. The phrase is also used to accuse nurses whose documentation is not complete. Incomplete documentation can dramatically affect a malpractice case.…

Medical Records: 10 Top Uses

Medical records have varied uses. LNCs are familiar with their role in evaluating liability, causation and/or damages. There are 10 other uses. Various state and federal laws require that certain events, such as births and deaths, as well as certain diseases, be reported to public health agencies. Written medical record information facilitates compliance with these…

Medical Records: Top 12 Uses

The medical record serves many purposes, including its role in evaluating a potential or actual case. Medical Records – top uses 1. Written documentation provides historical data that could be used for diagnosing the patient’s current medical episode as well as future medical events. Accurate medical information about previous health conditions, allergies, treatments, and outcomes…

Breaking Down the Nursing Home Chart

Nurses without long-term care experience may be very hesitant to review one of these cases due to their lack of knowledge of these industry specific records. Once you understand where important information is located within a nursing home chart you can use them to create your analysis of the matter. Minimum Data Set in a…

Wound treatment 101

Legal nurse consultants will encounter many medical records that detail types of wound treatment. Hyperbaric oxygenation, negative pressure wound therapy, surgical closure, debridement, and topical dressings are all treatment options for wounds. A combination of these modalities may be utilized to treat a wound. Virtually all wound treatment regimens incorporate the utilization of a topical…

Medical record analysis with multiple computer monitors: tips for efficiency

Attorneys and legal nurse consultants are increasingly performing medical records analysis using multiple monitors and Adobe Acrobat. Advantages of multiple monitors for medical records analysis 1. Multiple monitors make you more efficient. Time is money. Multiple monitors increase your speed which therefore increases the amount of work product that you turn out which therefore increases…