2. Another way to get your relationship going with the decision maker is to request an introduction. This is overlooked in a lot of cases. My favorite way to request an introduction is an email introduction. This is where somebody you know knows somebody who needs your services and you ask the person you know to create an email with your name and the other person’s name on it, a little bit about each of you and then just type “enjoy” and hit send. That way you have permission to interact with your decision maker and to request an introduction or rather to request a meeting. This has been a very, very successful way of starting a relationship with a decision maker.

3. This next way you could go is through networking. A lot of people spend a lot of time networking, but not all networking events were created equal. You could be in a roomful of a lot of people and have nobody in that room who needs your services or knows anybody who needs your services. That’s probably not the best use of your time. You can also be in a roomful of people where there’s only one person who needs your services and that could be a very good use of your time.

Networking success story: One of my clients one time identified that a person that she wanted to introduce herself to was going to be a speaker at a networking event. She drove an hour and a half to see this speaker, not because she was interested in the subject matter but because she wanted to meet the speaker, say something important that mattered and have the speaker invite her to come to the office for a meeting. So we strategized for about an hour about what she could say in about 15 seconds – when there was a crowd of people around that speaker – that would matter and the speaker would invite her in for the meeting. After the hour we had our strategy. She drove the hour and a half and the whole thing went off as planned. She has met with the decision maker and they are in the proposal phase right now.

There’s a lot when it comes to networking in terms of figuring out where is the best place to spend your time, but also the messaging that you use when you’re at a networking event is critical.

This guest blog post was written by Caryn Kopp and was extracted from The Path to Cash. Get the replay, transcript or CD of this multimedia program.

Day one of exhibiting
The critical times for meeting attorneys are during registration on the first morning, before the conference opens, during breaks and at lunch time. Company X’s personnel set up their booth the night before by laying out candy, balloons, mugs and pens. They had a few pieces of literature out. There were no signs to indicate what they did other than the name on the wall created by the curtains.

We got to the exhibit area at 7:20 AM and set up everything that had been stored under the table overnight. Attorneys began arriving at around 8:00, picked up their registration material and drank coffee and ate breakfast right in front of our tables. They also roamed up and down the rows of exhibitor tables, talking to exhibitors and picking up giveways. At 9:15 AM they moved into the conference rooms and by 9:30 AM, most of the exhibit area was empty of attorneys. Between 8:00-9:30 AM, we handled a steady stream of attorneys, answered questions, gave away material, collected business cards, and identified some very interested attorneys. Company X’s table was unattended. People who walked by there took mugs, candy and pens, but there was no one to interact with them.

At 9:30 AM, Company X’s personnel arrived – three of them – and sat behind the booth. I was still astounded that they would leave the table unattended during the critical time of the conference. I told the owner that there were lots of people who came by their booth. I received a blank stare.

Company X’s booth personnel changed frequently during that day. We observed one interchange that was astonishing. An attorney came over and warmly greeted the owner and said, “Nice to meet you. We use you all the time.” The owner asked him his name, which he gave, and then flatly said, “I have never heard of you.” I wanted to kick her under the table and ask, “Couldn’t you have at least faked being gracious?”

Day two of exhibiting
The next morning Company X’s workers showed up after the morning sessions began. They spread out a few pieces of candy and a small stack of reusable grocery bags with their logo and left after about 10 minutes. The entire rest of the day, which lasted until 2 PM when the exhibit hall closed, they were missing. Why would a vendor spend thousands of dollars to have a table in the exhibit hall and not be there? Exhibiting is a wonderful chance to form relationships, strengthen relationships, learn from clients and prospects, socialize with other vendors, and spy opportunities. Get the most from your exhibiting dollars by showing up!

Patricia Iyer is president of Med League. She has been exhibiting at attorney conferences since 1995; it has built the company. Along with Gary Bronga, she presented a webinar on Tradeshow Exhibiting . Learn how to most effectively spend your dollars and time exhibiting at tradeshows for attorneys by watching the digital download.

Falls are a public health problem that has no geographic boundaries or age restrictions. Anyone can fall. Most individuals know of someone, if not themselves, who has fallen. In early childhood years, unless confined in movement or mobility from disease, children fall to the ground quite often, for instance, during childhood play. Some individuals may continue to fall throughout their life and into advancing older years, by virtue of lifelong patterns of clumsiness, “accidentally”, from progressive diseases, or from combinations of any or all of these factors. A critical question is: “Does this mean that these falls could have been prevented?” The answer to this question depends on the circumstances of the fall and its likely cause, which can only be answered when the right set of questions is asked and answered.

Falls are a national public health problem because of their magnitude (high incidence), wide scope (affecting all ages, from childhood through older years), and their potentially devastating aftermath (ranging from fatality to serious physical injury or impairment). Fall reduction is a priority. National campaigns have been directed at the two groups at the extremes of the age continuum, the very young (i.e. children) and those over age 65 (older adults). The National Safety Campaign for Safe Kids focuses on injury prevention in youth; the Falls Free campaign funded by the National Council on Aging focuses on fall and injury prevention among older adults. In both age-groups, falls are the leading cause of unintentional injuries.

From a clinical practice stance, a fall occurring when the patient is eased to the ground could still result in an injury, thus there are legal ramifications from all falls occurring in a medical care setting (See Chapter 6). The CMS definition of this type of fall is broad enough for good reason – so as to make clear that any and all events whereby the person ends up on the floor constitutes a fall. Practitioners or facilities may fail to consider this type of fall, as an actual fall (as reflected in their definition of a fall as obtained in the facility policy or procedure manual for fall prevention). Healthcare providers may conceptualize this type of fall as one with which they assisted, therefore, it is not “really” a fall. When an older adult has a diagnosis of osteoporosis, any impact with a hard surface such as the ground or floor or even bed-rail, can potentially produce a break in the already thinned and fragile bone, resulting in a fracture.

If the healthcare provider fails to document this incident as a fall in the medical record because he or she considers it to be an “assisted to the ground” fall, or if an incident report is not completed as required by policy, the only potential sufferer is the patient. Unexplained fractures or acute or chronic pain localized to an extremity may indicate that a fall occurred. The failure to record a fall, even though perceived as non-harmful, provides the appearance of a cover up. This may be construed as tampering with the medical record, and significantly increases liability.

Learn more about how to analyze the liability and damages associated with patient falls cases. See our Patient Falls Value Pack

How can you not be?

1. Use simple, direct language. Avoid confusing terms, such as “herein”, “aforementioned”, and “execute”. I remember a deposition in which the plaintiff was asked if he executed the document. He was clearly bewildered when he replied, “Did I do what to the document?” When we use simple terms in our writing, it carries over to our speech. Define medical terms.
2. Avoid long, convoluted sentences. The reader may forget the point by the time he gets to the end of the sentence. Sentences that fill a paragraph cry out to be broken into pieces. The average sentence length should be between 20 to 25 words.
3. Define your points at the beginning of a paragraph to give the reader a road map. And then explain each point, in the order in which you first presented them.
4. Avoid idiosyncratic capitalization. I see terms like “Standard of Care”, “Nurse”, and “Hospital” capitalized in sentences when the lower case form is proper.
5. Provide summaries to define the main points. Summaries may be at the beginning and the end of the document.
6. Define terms that are going to be unfamiliar to your reader. Will Rogers said, “Everyone is ignorant, just about different stuff.” The goal of communication is to state something in a way that the reader/client will understand.
7. Activate the readability statistics in your word processor. Passive voice sentences should not exceed 10%. The active voice is direct. Passive voice is cumbersome. “He was taken to the operating room” is passive. “He went to the operating room” is active.

Think about your audience when you write. Simplify, edit, and proofread. You will create grateful readers.

Patricia Iyer is president of Med League. She has authored, coauthored or edited more than 125 books, articles, online courses, case studies, and chapters of her own work. She has proofread and edited hundreds of chapters and expert witness reports of others. She has spent thousands of hours proofreading other people’s work.

Read more on this topic: Writing Handbook for LNCs

The assessment of fall risk is the responsibility of medical, nursing, and rehabilitation staff of the nursing home. Every nursing home resident is to be evaluated with the MDS (Minimum Data Set) to identify risk factors for falls, among other things. Additionally, a facility (or chain) may have its own fall risk assessment tool and a specific policy and procedure describing its use. Most homes will have a fall assessment tool as part of its nursing or rehabilitation (physical and/or occupational) therapy admission evaluation.

Note that fall risk assessment is performed as a screening measure (primary level of prevention) for all residents admitted to a nursing home facility (to detect and modify existing risks to fall), and it is repeated as part of a post fall assessment.

Although there are numerous published fall risk assessment tools, there is no single tool that is considered “standard” in the nursing home. Although some falls may be isolated events, most residents who have fallen should have a thorough post-fall assessment. This is especially necessary for those with a history of recurrent falls, since a history of falls is identified as a major risk factor for subsequent falls.

Discovery tip: Does the facility have fall risk assessment tools and separate post-fall assessment tools for evaluation of the falling older adult?

Risk factors
An essential aspect of any fall assessment tool is the consideration of risk factors for injurious falls. See below for a list of risk factors that should prompt a thorough evaluation and plan of care.

Circumstances
New admission to nursing home
Recent transfer from hospital or other setting
Recent transfer from another unit or room
Responding to bladder or bowel urgency
Attempting to remove a physical restraint
Climbing over or around side rails
History of recurrent falls

Intrinsic Factors
Functional
Loss of leg or arm movement
Unilateral (one-sided) weakness
Recent, rapid decline in functional status (ability to care oneself)
Musculoskeletal
Arthritis
Osteoporosis
History of fracture
Post-amputation
Neuro-muscular
Stroke
Parkinson’s disease
Neuro-sensory
Impaired vision
Impaired hearing
Dizziness
Vertigo
Polyneuropathy (reduced sensation of extremities) of diabetes, peripheral vascular disease or alcoholism
Pain, especially of joints
Psychiatric
Delirium (often indicative of underlying, acute, physical illness)
Dementia
Depression
Acute illness
Infection
Myocardial infarction

Extrinsic Factors
Medications
Polypharmacy
Cardiac, Antihypertensives, and diuretics
Psychoactive
Sedatives, anti-anxiety agents
Benzodiazapines
Valium
Chloral hydrate
Antidepressants
Tricyclic antidepressants
Selective serotonin-reuptake inhibitors
Trazodone
Antipsychotics
Haldol

Environmental Hazards
Slippery floors, especially from urine
Glare from highly polished floors
Absence of night lights
Unstable furniture
Low chairs without armrest support or seat back
Low toilet seats without secure gab bars
Assistive devices
Wheelchair
Walker
Cane, especially if poorly maintained or not fitted properly to the individual resident’s size and needs
Physical restraints, including side rails

Behavioral Factors
Risk-taker personality or impulsive mobility (may be secondary to stroke or impaired cognition)
Tendency to stand quickly, especially from bed or immediately after a meal

As you can see, there are multiple risk factors that affect the risk of falling. The standard of care requires the long term care nurse to consider these when assessing risk of falls.

Learn more about how to analyze the liability and damages associated with patient falls cases. See our Patient Falls Value Pack

When asked what you do at a party, you no longer fall over your words.

You actually believe, deep in your heart, that you are as valuable as your brochure claims.

Your children are finally impressed.

Your attorneys take one look at a case and call you instead of trying to do everything themselves and messing it all up.

~Alice Adams

You get in a fender bender and pray the guy you rear ended doesn’t have a TBI!

~Tracy Bedford

You start to think everyone at the doctor’s office has a case.

~Paula Bell

You would never think of crossing the street without a crosswalk.

~Abbie Citron

You are reviewing medical records like you are a CSI.

Excited when the records arrive and you can start the review.

Trying to find old classmates who are attorneys.

You go on vacation, check in your hotel and run for the phone book to look up attorneys in the area!

~Janis Cox

You listen to all the pharmaceutical ads on television with a new attention to detail about side effects.

You realize that forensic television shows are 98% Hollywood.

Your Christmas gift list gets longer with client remembrances and your clinical library is doubled by law books.

~Pamela Graham

You go into a deposition loaded for bear and score a direct hit.

You go to the courthouse and all the attorneys smile at you like you belong and someone asks you for directions.

You suddenly realize you have the knowledge to pay it forward to help others who are just starting out.

~Jane Grametbour

These contributions are from Path to Legal Nurse Consulting: Collective Wisdom of Successful LNCs. Patricia Iyer and Alice Adams edited this brand new 200 + page book. Learn from 25 successful LNCs who shared their triumphs and strategies to get started in this rewarding legal nurse consulting field. Get one of the first copies by ordering today.

computerized medical records and medical errors

There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages.

Join Pat Iyer and Lee Houston, two legal nurse consultants, for a practical program on how to analyze computerized medical records. Computerized Medical Records: Medical Legal Analysis is an all new one hour multimedia program geared to attorneys and legal nurse consultants. You’ll come away with concrete suggestions for making it easier to review records on the computer monitor. This April 10, 2012 program is at 8 PM Eastern. Buy the CD, MP3 audiofile or transcript if you can’t join us that night. Get details about practical program on how to analyze computerized medical records here.

From Patricia Iyer and Sharon Koob, Nursing Documentation, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition

forensic issues of computerized medical records

There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages.
• Access to a medical record may be electronically limited. For example, a nursing assistant may be permitted to only enter vital signs but not review orders, laboratory results, or write nursing notes. A paper medical record may be viewed by anyone.
• It is possible to determine who has accessed an electronic chart.For example, Registered Nurse Charles Cullen, who confessed to killing many patients, was finally caught in 2003 through the use of computers. His excessive use of digoxin, a medication used to kill his victims, was preceded by accessing medical records of patients to whom he was not assigned. The digoxin was stored in a computerized drug dispensing cart, which recorded his removal of the drug.
• Tampering with the medical record is much more difficult to do with an electronic system.Software typically permits the healthcare professional to correct errors in typing and phrasing immediately after the error is made. Software programs contain a feature that makes the entry unalterable after a certain time or event. Typically, the entry is made unchangeable once it is authenticated. There is also a regularly scheduled backup time to store data, making it impossible for someone to delete previous entries once they are saved. If a correction (such as an incorrect entry, misspelled word, or typographical error) is to be made after an entry is saved or authenticated, the software program should contain a way to accomplish this task. This is often achieved in the same way it is done in paper systems, by bracketing the mistaken entry, adding the correct information, and giving a reason for the change, such as “wrong chart.”A clock embedded in the software program indicates the precise time and date of an entry; and in this way it becomes impossible to backdate information to make it look as if it was entered earlier. Each entry in the electronic medical record carries a time and date stamp, as well as the identity of the user.
• With sufficient safeguards in place, an electronic record is more reliable and less likely to be lost.

Join Pat Iyer and Lee Houston, two legal nurse consultants, for a practical program on how to analyze computerized medical records. Computerized Medical Records: Medical Legal Analysis is an all new one hour multimedia program geared to attorneys and legal nurse consultants. You also come away with concrete suggestions for making it easier to review records on the computer monitor. This April 10, 2012 program is at 8 PM Eastern. Buy the CD, MP3 audiofile or transcript if you can’t join us that night. Get details about computerized medical records analysis here.

From Patricia Iyer and Sharon Koob, Nursing Documentation, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition

Critical thinking point for the legal-nurse consultant: Were there a variety of chair-types, thereby adding customization to patient needs? Analyze the types of chairs purchased by the nursing facility.

Remaining in a reclining position for most of the day will eventually result in the decreased ability to sit up in a wheelchair or straight back chair due to loss of abdominal muscle strength. This will adversely affect the resident’s ability to eat or swallow liquids safely (without aspiration). Treatment of weak abdominal muscles usually requires a process of incrementally reducing the angle of recline over time; and supervision of this process is done by an occupational therapist.

Most nursing home residents spend the majority of the day and early evening hours in a wheelchair. Wheelchairs were originally designed for transport; their sling seats do not provide adequate support for long periods of sitting. Many products are available to adapt the chair to the resident’s seating needs.

If the resident spends more than an hour per day in a wheelchair or hard plastic/wood chair, the chair should, at minimum, have some type of pressure-relieving seat cushion. Anti-tippers applied to chair will prevent the resident from “flipping” a wheelchair or chair forward or backward.

Other adaptations for the wheelchair include a wedge cushion inserted under the resident’s buttocks and thighs which tilt the resident backward. A wedge seat prevents the resident from sliding forward. Similarly, leaning to the side is corrected with lateral supports or cushions. Stroke victims with hemiplegia (one-sided weakness) are at risk for shoulder subluxation (partial dislocation) if the weakened arm slips off the side of the chair. This can be prevented with devices attached to a wheelchair: an arm trough, elevated armrest, lateral arm support, or half tray. A full tray table is not necessary. A leg panel will prevent legs from falling backward off foot pedals or between calf pads. A head extension can be added to a wheelchair, or other chairs, to help keep the resident’s head erect and promote comfort. Also, “wingback” head extensions will prevent the resident’s head from leaning to one side.

The wheelchair itself can be individually fitted to the resident’s size. For example, pediatric wheelchairs are available for very small residents as are extra-wide chairs for obese or larger residents. “Walking” in the wheelchair (i.e., using feet to propel forward or backward) is easier for some residents than pushing the wheels with their arms. Hemi-height wheelchairs that can be adjusted to the resident’s lower leg length can facilitate pushing the wheelchair with the legs. This adjustment creates safe transport while promoting muscle strengthening exercise to the lower extremities.

Critical thinking point for the legal nurse consultant: Given the patient’s height and body weight, was the chair an appropriate size? If the older adult slides out of the chair, it may be too big or fail to have proper pillow supports. Was the foot rest utilized, which can help reduce the chances of slippage from the chair seat? Was the patient wearing shoes or anti-skid slippers while sitting in the chair?

The need for all of the adaptive equipment described can be determined by a physical/occupational therapist, nurse or physiatrist with the attending physician’s orders. Individualized seating, however, is only part of the solution to prevent falls. Residents need regular exercise. No matter how comfortable the chair, residents need to get up periodically. Those unable to move themselves should receive assistance of the staff in changing positions and, if possible, in standing or walking at least twice a day as part of a rehabilitation or restorative nursing program. Also, because sitting up can be tiresome, residents may need to nap for one to two hours in the early afternoon, depending on their condition.

Some residents will attempt to get up from even the most comfortable chair because of boredom. A stimulating activities program is an important part of a falls prevention program. Also, an activity apron or half tray with an activity board can be help to stimulate the resident with dementia.

Learn more about how to analyze the liability and damages associated with patient falls cases. See our Patient Falls Value Pack