Emergency Department Medical Records Part 1

by June 20, 2014 » Add the first comment.
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Use your legal nurse consulting skills to help attorneys understand emergency department medical records. Here are some of the points that affect personal injury cases. • Who first saw the patient? Usually a triage nurse will evaluate the patient before the patient is officially checked into the emergency department (ED). • How did the patient [...]

Personal Injury Medical Records – What to Look For

by June 16, 2014 » Add the first comment.
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Physician office records hold the keys for analyzing personal injury cases. They can make or break a plaintiff’s case. It is crucial that you as the legal nurse consultant be able to read and decipher these records in a personal injury case. Look for these pieces of information. Are you able to read the physician’s [...]

Missing Medical Records

by June 13, 2014 » Add the first comment.
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How do you know as a legal nurse consultant that medical records are 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 pages to be missing. This often happens because of inattention during the process of copying the [...]

3 Ways to Pitch Your Value to Attorneys: Medical Records

by June 10, 2014 » Add more comments.
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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. The key to medical record analysis is the interpretation of information found in the records, identification of information missing from the records, and the [...]

Why I like Paper Medical Records

by June 6, 2014 » Add more comments.
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Sometimes I feel a little like a dinosaur. I love paper records. I like them printed out, organized and ready for my review as a legal nurse consultant. Medical record review: which is faster? Although we receive PDFs of medical records, we use them to print out paper records. Using preprinted medical record tabs, we [...]

Computer Provider Order Entry Part 2

by June 3, 2014 » Add the first comment.
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Legal nurse consultants are increasingly receiving electronic health records for analysis. How do these records help patients and providers?  1. Facilities using EHRs and computer provider order entry could gain greater market share A benefit associated with implementation of an EHR relates to the facility’s standing in the area it serves. Improved quality of patient [...]

Computer Provider Order Entry: Saving Lives and Money Part 1

by May 30, 2014 » Add the first comment.
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Legal nurse consultants increasingly receive electronic health records (EHRs) for analysis. How do EHRs save money and lives? 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 in hospitals that could have been prevented are numbered at [...]

Missing Documentation

by May 27, 2014 » Add the first comment.
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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 we don’t get full records or pages [...]

Nurse Practitioners: Expanding Role, Expanding Liability

by May 23, 2014 » Add the first comment.
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New York became the 18th state to no longer requiring experienced nurse practitioners to have a written practice service agreement with a physician. Experienced nurse practitioners (who have more than 3,600 hours of practice) will be able to be more independent beginning January 1, 2015. As patients receive insurance as a result of the Affordable [...]

Is it Substandard Charting or Fraudulent Charting? Part 2

by May 20, 2014 » Add the first comment.
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In Part 1, I explained how you can spot substandard charting. Suspicious charting goes one step further to raise concern about the medical records. Suspicious Charting 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 filing a malpractice claim. [...]

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