Table of Contents

Medical Legal Aspects of Medical Records, Second Edition

Patricia W. Iyer, MSN RN LNCC and Barbara J. Levin BSN, RN ONC, LNCC

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Volume I (Blue) (jump to Volume II)

Chapter 1: Generating and Preserving Medical Records
Cynthia L. Northcutt, BSN, RN, JD and Mary Ann Shea, JD, BS, RN
1.1 Introduction
1.2 Definition and Purposes of the Medical Record
1.3 HIPAA and Medical Records: Administrative Simplification, Privacy, and Confidentiality
1.4 Privacy and Confidentiality
1.5 The Field of Health Information Management
1.6 Ownership of the Medical Record
1.7 Standards of Record-Keeping and Patient
1.8 Retention of Medical Records
1.9 Storage and Destruction of Old Medical Records
1.10 Additional or Supplemental Medical Records that May Exist Outside the Main Chart
1.11 Summary

Chapter 2: Legal Aspects of Charting
Patricia Iyer, MSN, RN, LNCC
2.1 Introduction
2.2 Timing of Charting
2.3 Format of Charting
2.4 Content of Charting
2.5 Summary

Chapter 3 : Obtaining and Organizing Medical Records
Patricia Iyer, MSN, RN, LNCC and Jane Barone, BS, RN, LNCC
3.1 Introduction
3.2 Who Asks for the Records
3.3 What Records to Obtain
3.4 When to Ask for Records
3.5 How to Request Records and Other Information
3.6 Initial Intake of Records
3.7 Ensuring Records are Complete
3.8 Organizing Hospital Records
3.9 Organizing Rehabilitation Facility Records
3.10 Organizing Nursing Home Records
3.11 Organizing Physician Office Records
3.12 Organizing Ambulatory Care Records
3.13 Deciphering Records
3.14 Handling of Records
3.15 Summary

Chapter 4 : Analyzing Medical Records
Marguerite Barbacci, BSN, RNC, LNCC, and Patricia Iyer, MSN, RN, LNCC
4.1 Introduction
4.2 Indexing
4.3 Analysis of Medical Records
4.4 Review of Personal Injury Records
4.5 Summary

Chapter 5: Charting Systems
Patricia Iyer, MSN, RN, LNCC
5.1 Introduction
5.2 Source-Oriented Charting
5.3 Narrative Charting
5.4 Problem-Oriented Charting (SOAP)
5.5 PIE Charting
5.6 Focus Charting(r)
5.7 Charting by Exception
5.8 FACT Charting
5.9 Summary

Chapter 6: Computerized Medical Records
Patricia Iyer, MSN, RN, LNCC and Hilary Flanders, MPH, RN-BC, RRT
6.1 Introduction
6.2 The Paper Chart
6.3 Use of Computers to Prepare Medical Records
6.4 Definitions of Computerized Medical Records
6.5 Status of Computerized Medical Records
6.6 Advantages and Disadvantages of Computerized Records
6.7 Bedside Terminals
6.8 Barriers to the Introduction of Nursing Information Systems
6.9 Implementation Challenges
6.10 Summary

Chapter 7 : Preparing for E-discovery of Electronic Medical Record Information
G. Ann Geyer, Esq.
7.1 Introduction
7.2 The New E-discovery Rules
7.3 Managing E-discovery of EMR Information
7.4 Summary

Chapter 8 : Billing and Coding
Agnes Grogan, BS, RN
8.1 Introduction
8.2 Value of Bill Review in Legal Setting
8.3 Basics of Medical Billing
8.4 Codes
8.5 Coding Responsibilities
8.6 Resources
8.7 Generation of Bills
8.8 Fraudulent Billing
8.9 Miscellaneous Issues
8.10 Summary

Chapter 9 : Health Insurance Portability and Accountability Act (HIPAA)
Marilyn Frank-Stromborg, EdD, JD, FAAN, Kenneth Burns, RN, PhD, Bob Morgan, Esq., and Desirée Bromme Sierens, BA
9.1 Introduction
9.2 History of HIPAA
9.3 Who is Regulated by HIPAA?
9.4 How HIPAA Impacts Medical, Nursing, and Legal Arenas
9.5 Frequently Asked Questions About HIPAA
9.6 The Effect of HIPAA on Healthcare Providers and Law Firms
9.7 Privacy Issues
9.8 HIPAA Case Study
9.9 The Next Phase: Security Rules, Transaction and Code Set Standards, and Identifier Standards
9.10 Conclusion

Chapter 10 : Patient Safety Initiatives and Medical Records
Patricia Iyer, MSN, RN, LNCC and Susan Mellott, RN, CPHQ, FNAHQ, PhD
10.1 Introduction
10.2 The Current Healthcare Environment
10.3 The Joint Commission
10.4 The Joint Commission Survey Process
10.5 National Patient Safety Goals
10.6 NPSG.01: Improve the Accuracy of Patient Identification
10.7 NPSG.02: Improve the Effectiveness of Communication Among Caregivers
10.8 NPSG.03: Improve the Safety of Using Medications
10.9 NPSG.04: Eliminate Wrong-Site, Wrong-Patient, Wrong-Procedure Surgery
10.10 NPSG.05: Improve the Safety of Using Infusion Pumps: Ensure Free Flow Protection
10.11 NPSG.06: Improve the Effectiveness of Clinical Alarm Systems
10.12 NPSG.07: Reduce the Risk of Healthcare-Acquired Infections
10.13 NPSG.08: Accurately and Completely Reconcile Medications Across the Continuum of Care
10.14 NPSG.09: Reduce the Risk of Patient Harm Resulting From Falls
10.15 NPSG.10: Reduce the Risk of Influenza and Pneumococcal Disease in Older Adults
10.16 NPSG.11: Reduce the Risk of Surgical Fires
10.17 NPSG.12: Implementation of Applicable National Patient Safety Goals and Associated Requirements by Components and Practitioner Sites
10.18 NPSG.13: Encourage the Active Involvement of Patients and Their Families in the Patient’s Care as a Patient Safety Strategy
10.19 NPSG.14: Prevent Healthcare-Associated Pressure Ulcers (Decubitus Ulcers)
10.20 NPSG.15: The Organization Identifies the Safety Risks Inherent in its Patient Population
10.21 NPSG.16: Improve Recognition and Response to Changes in a Patient’s Condition
10.22 Universal Protocol
10.23 The Leapfrog Group
10.24 National Quality Forum
10.25 Institute for Healthcare Improvement Initiatives
10.26 Summary

Chapter 11: Presuit Use of Medical Records
Leilani Kicklighter, MBA, RN, ARM, DFASHRM, CPHRM, LHRM
11.1 Introduction
11.2 Incident Reports and Reporting to Risk Management
11.3 Confidentiality of Incident Reports
11.4 Regulatory Standards
11.5 Sequestering Records
11.6 The Record Is What the Record Is
11.7 Potentially Compensable Events (PCEs)
11.8 Expert Witnesses
11.9 References
11.10 Reviewing the Medical Record
11.11 Insurance Carrier’s Involvement
11.12 Summary

Chapter 12 : Attorney Use of Personal Injury Medical Records
Jeffrey I. Zimmerman, Esq.
12.1 Introduction
12.2 Are the Relevant Records Complete?
12.3 History of Injury
12.4 Use of Medical Records
12.5 Analysis of Medical Records
12.6 Communicating with the Physician
12.7 Battle of the Titans, or How to Play David to the Insurance Carrier’s Goliath
12.8 Summary

Chapter 13 : Attorney Use of Medical Records in a Medical Malpractice Case
Peter I. Bergé, Esq., P.A.
13.1 Introduction
13.2 The Role Of Medical Records in Evaluating Medical Malpractice Claims
13.3 Pitfalls in Obtaining Medical Records
13.4 Preparing to File Suit
13.5 Use of Records After Suit is Filed
13.6 Use of Records at Deposition
13.7 Use of Records at Trial
13.8 Summary

Chapter 14: Preventing Healthcare-Acquired Conditions Means Never Having to Say You’re Sorry
Carol Ann Armenti, MA, JD
14.1 Introduction
14.2 The Healthcare Climate Begs Change
14.3 Financial Climate Motivates
14.4 Payment Implications
14.5 DRA Revisited
14.6 Unintended Consequences
14.7 Documentation Implications
14.8 Summary

Chapter 15 : Tampering with Medical Records
Roy Konray, Esq. and Patricia Iyer, MSN, RN, LNCC
15.1 Introduction
15.2 Substandard Charting
15.3 Suspicious Charting
15.4 Definitions of Spoliation
15.5 Spoliation Inference
15.6 Implications of Spoliation
15.7 Organizing Medical Records
15.8 Techniques for Tampering with Medical Records
15.9 Detection of Tampering
15.10 Strategic Decisions
15.11 Defense of Spoliation Claims
15.12 Summary

Chapter 16: Forensic Examination of Medical Records
A. Frank Hicks, DABFDE
16.1 Introduction
16.2 What Is a Forensic Document Examiner and How Is One Located?
16.3 How Can a Forensic Document Examiner Assist the Attorney?
16.4 The Importance of Knowing the Charting Habits of the Medical Personnel
16.5 Summary

Chapter 17: Forensic Medical Records
Virginia A. Lynch, MSN, RN, FAAN and Jamie Ferrell, BSN, RN, DABFN, CA/CP-SANE, SANE-A, CMI-III, CFN
17.1 Introduction
17.2 Definitions of Forensic Nursing
17.3 Forensic Professionals
17.4 Location and Provision of Forensic Services
17.5 Common Forensic Issues
17.6 Trauma Quality Management (TQM) and Forensic Cases
17.7 Principles of Forensic Documentation
17.8 What Is Forensic Evidence?
17.9 Commonly Occurring Forensic Circumstances Requiring Evidence Recovery
17.10 Bite Marks
17.11 Gunshot Wounds
17.12 Forensic Toxicology
17.13 Sexual Assault
17.14 Ethical Issues and Legal Precedents
17.15 Summary

Chapter 18: Autopsy Reports
Cyril H. Wecht, MD, JD, Steven A. Koehler, MPH, PhD, and Lone Thanning, MD
18.1 Introduction
18.2 Death Investigation System Developmen
18.3 The Death Investigation Systems in Modern America
18.4 The Stages of Death
18.5 Pronouncing and Criteria for Reporting a Death
18.6 The Death Investigation Team
18.7 The Forensic Pathologist
18.8 Types of Autopsies
18.9 Exhumation of a Body
18.10 Key Components of the Forensic Reports
18.11 Definition: Medical-Legal
18.12 Summary

Volume II (Green)

Chapter 1: Complementary and Alternative Medicine‹Chiropractic, Acupuncture, and Massage
Douglas R. Briggs, DC, Dipl.Ac.(IAMA), DAAPM, John A. Amaro, DC, Dipl.Ac.(IAMA), Dipl.Ac.(NCCAOM), Kimberly Combs, LMT, and Stacy S. Cohen, DC
1.1 Chiropractic
1.2 Acupuncture
1.3 Massage
1.4 Integrative Medicine

Chapter 2: Dental Records
Barry C. Cooper, DDS
2.1 Introduction
2.2 Background of Dentistry: Terminology
2.3 Extent of Dental Records
2.4 Disorders of Dental/Oral and Adjacent Structures
2.5 Dental Procedures/Treatments
2.6 Complications of Treatment
2.7 Documentation Practices
2.8 Use of a Dental Expert Witness
2.9 Summary

Chapter 3: Home Care Records
Barbara Mladenetz Weber Berry, MSN, RN
3.1 What Is Home Care?
3.2 Documentation in Home Care
3.3 Risks in Home Care
3.4 At-Risk and Non-Compliant Client
3.5 Home Care Cases
3.6 Recommendations for Reviewing the Home Care Record
3.7 Summary

Chapter 4: Independent Medical Examination
Marjorie Eskay-Auerbach, MD, JD
4.1 Introduction
4.2 The Examiner’s Role
4.3 Choice of an IME Physician
4.4 Differing Legal Perspectives on IMEs and Caveats
4.5 Scheduling an IME or Record Review
4.6 Structure of the Independent Medical Examination and Report
4.7 Review of Medical Records
4.8 Medical/Legal Controversies
4.9 Impressions and Professional Opinions
4.10 Evidence-Based Medicine
4.11 Role of the AMA Guides
4.12 Summary

Chapter 5: Office-Based Medical Records
Keith M. Starke, MD, FACP and Ginny Tucci Starke, MSN, RN
5.1 Introduction
5.2 Paper-Based Systems
5.3 Sections of Information Found in the Office Records Related to the Patient
5.4 Electronic Medical Records
5.5 Governing Organizations’ Documentation Guidelines
5.6 Physician Notes
5.7 Referrals or Consultations
5.8 How to Evaluate Office Medical Records
5.9 Is the Physician the Only Examiner?
5.10 Is There Office Nurse Documentation?
5.11 Does the Office Have a Protocol for Performing and Communicating Test Results?
5.12 How Does the Office Handle Phone Call Documentation?
5.13 Is There Documentation of Referral When Necessary?
5.14 Are There Red Flags Present in the Medical Record?
5.15 Patient Behavior
5.16 Summary

Chapter 6: Ophthalmology Records
Elliott M. Korn, MD
6.1 Introduction
6.2 Providers of Eye Care
6.3 Visual Acuity
6.4 Clinical Examinations
6.5 Eye Symbols and Abbreviations
6.6 Refractive Errors
6.7 Ocular Structures
6.8 Disease States
6.9 Summary

Chapter 7: Emergency Medical Services Records
Mary Fakes, RN, MSN and Scott A. Mullins, AAS, EMT-P
7.1 Introduction
7.2 History and Development of EMS Systems
7.3 Types of Services
7.4 EMS Certifications
7.5 Types of Patient Transports
7.6 Transport and Crew Responsibilities
7.7 Medical Direction
7.8 Documentation
7.9 Refusal of Care
7.10 Do Not Resuscitate
7.11 Controlled Substances
7.12 Communications
7.13 Termination of Resuscitation in the Field
7.14 Summary

Chapter 8: Emergency Department Records
Dana Stearns, MD
8.1 Introduction
8.2 The Triage Process
8.3 Documentation of Triage and Treatment
8.4 Diagnosis (DX)
8.5 Patient Management
8.6 The Trauma Patient
8.7 Documentation of Patient Management
8.8 Summary

Chapter 9: Critical Care Records
Kathleen C. Ashton, APRN, BC, PhD
9.1 Introduction to Critical Care Nursing
9.2 Types of Units
9.3 Standards of Critical Care Nursing
9.4 The Practice of Critical Care Medicine and Nursing
9.5 Documentation Issues
9.6 Types of Records and Systems
9.7 Use of Computerized Records
9.8 The Bedside Flow Sheet
9.9 Physician Documentation
9.10 Comparison of Records by Type of Institution: “Magnet” Status
9.11 Special Circumstances Encountered in Critical Care
9.12 Sources of Liability
9.13 Summary and Recommendations

Chapter 10: Diagnostic Testing
Bruce Bonnell, MD, MPH
10.1 Introduction
10.2 Diagnostic Tests Involving Blood Work
10.3 Microbiology
10.4 Imaging Tests
10.5 Testing in Cardiology
10.6 Summary

Chapter 11: Intravenous Therapy Records
Susan Masoorli, RN
11.1 Introduction
11.2 Peripheral Vascular Access Devices
11.3 Central Venous Access Devices
11.4 Site Monitoring Documentation
11.5 Legal Issues
11.6 Vascular Access Device Complications
11.7 Conclusion

Chapter 12: Long-Term Care Records
Gloria Blackmon, AAS, BSN, RN-BC, LNHA, Patricia Iyer, MSN, RN, LNCC, Angela Tobias, RN, BSN, MSHSA, LNCC, CHCC and Jill Thomas, RNC, CWOCN, LNHA
12.1 Introduction
12.2 Assisted Living
12.3 Long-Term Acute Care Hospitals (LTACHs)
12.4 Long-Term Care Diversity
12.5 Subacute Care
12.6 Overview of Documentation in Long-Term
12.7 The Importance and Purpose of Documentation in Long-Term Care
12.8 Regulations Pertaining to Long-Term Care Medical Records
12.9 Admission and Care Planning Documents
12.10 Nurses’ Notes
12.11 Additional Nursing Documentation
12.12 Ancillary Services Documentation
12.13 Physician Documentation
12.14 Medicare Documentation
12.15 Discharge Documentation
12.16 Careless Documentation
12.17 Summary

Chapter 13: Medical Surgical Records
Sally Russell, MSN, RN
13.1 Introduction
13.2 Respiratory System
13.3 Cardiovascular System
13.4 Neurological System
13.5 Renal System
13.6 Musculoskeletal System
13.7 Integumentary System
13.8 Endocrine System
13.9 Gastrointestinal System
13.10 Summary

Chapter 14: Medication Records
Michael T. Lennon, PharmD, MBA, RPh, JD
14.1 Introduction
14.2 Overview of Pharmacy Practice
14.3 Pharmacists’ Roles and Responsibilities
14.4 Medication Related Records
14.5 Legal Considerations
14.6 Summary

Chapter 15: The Nursing Process and Nursing Records
Patricia Iyer, MSN, RN, LNCC
15.1 Overview of Documentation
15.2 Why Do Nurses Document?
15.3 Trends in Charting
15.4 Initial Database: Admission Assessment
15.5 Priority Assessment Issues
15.6 Components of the Planning Process
15.7 Care Planning
15.8 Documentation of Discharge Planning
15.9 Documentation of Implementation
15.10 Implementation of the Plan
15.11 Documentation of Referrals
15.12 Documentation of Evaluation
15.13 Summary

Chapter 16: Obstetrical Records
Joanne McDermott, MA, RN
16.1 Introduction
16.2 Health History/Initial Pregnancy Profile
16.3 Estimating the Date of Birth
16.4 Prenatal Flow Sheet
16.5 Prenatal Testing
16.6 Intrapartum Care
16.7 Electronic Fetal Monitoring
16.8 Non-Reassuring Fetal Heart Rate Patterns
16.9 Pitocin Induction and Augmentation
16.10 Analgesia and Anesthesia
16.11 Cesarean Sections
16.12 Vaginal Birth after Cesarean (VBAC)
16.13 Labor and Delivery Summary
16.14 Complications in Pregnancy
16.15 Anesthesia Record
16.16 Operative Record
16.17 Post-Anesthesia Care Unit (PACU)
16.18 Computerized Charting
16.19 Commonly Used Obstetrical Abbreviations
16.20 Summary

Chapter 17: Orthopaedic Records
Barbara J. Levin, BSN, RN, ONC, LNCC and Howard Yeon, MD, JD
17.1 Introduction
17.2 Orthopaedic Definitions and Terminology
17.3 Traumatic Injuries
17.4 Essential Elements of the Musculoskeletal Trauma Patient’s Medical Record
17.5 Elective Orthopaedic Procedures
17.6 Essential Elements of the Elective Orthopaedic Patient’s Medical Record
17.7 Orthopaedic Complications
17.8 Nursing Care Plans
17.9 Summary

Chapter 18 : Pain Assessment and Management
Yvonne D’Arcy, MS, RN, CRNP, CNS
18.1 Introduction
18.2 National Guidelines for Pain Management
18.3 Elements of Pain Assessment
18.4 Pain Instruments
18.5 Documentation
18.6 Commonly Used Pain Medications
18.7 Specialty Pain Assessment and Documentation
18.8 Summary

Chapter 19: Pediatric Records
Susan G. Engleman, MSN, RN, APRN, BC, PNP, CLCP
19.1 Introduction
19.2 Basic Tips for Non-Medical Professionals Reviewing Medical Records
19.3 Why Are Pediatric Patients Different?
19.4 What Should the Child’s Chart Contain?
19.5 Red Flags in the Chart
19.6 Failure to Recognize Compensatory Mechanisms
19.7 How Do I Know if I Need a Pediatric Expert?
19.8 Conclusions: “Proceed with Caution”

Chapter 20: Perioperative Records
Jo Anne Kuc, BSN, RN, LNCC
20.1 Introduction
20.2 Preoperative Period
20.3 Pre-Surgical Phase
20.4 Intraoperative Nursing Documentation
20.5 Documentation of Anesthesia Care
20.6 Post-Anesthesia Care Unit Documentation
20.7 Outpatient Surgery Discharge
20.8 Summary

Chapter 21: Physician Documentation in Hospitals and Nursing Homes
Jeffrey M. Levine, MD
21.1 Introduction
21.2 Physician Roles and Responsibilities for Documentation
21.3 Forces That Shape Documentation
21.4 Accreditation Requirements
21.5 Summary

Chapter 22: Psychiatric Records
Wanda K. Mohr, RN, FAAN, PhD
22.1 Introduction
22.2 The Development of the Diagnostic and Statistical Manual of Mental Disorders
22.3 Use and Structure of the Diagnostic and Statistical Manual of Mental Disorders
22.4 Validity, Reliability, and Limitations
22.5 The Diagnostic Process
22.6 The Medical Record: From Diagnosis to Discharge
22.7 The Multidisciplinary Team and Documentation in the Medical Record
22.8 Psychiatric Terminology and Accuracy in Communication in the Medical Record
22.9 Uses and Misuses of Terminology
22.10 Documenting Special Circumstances in the Medical Record
22.11 Summary

Chapter 23: Physical Therapy Records
Gwen Simons, PT, JD, OCS, FAAOMPT
23.1 Introduction
23.2 What is Physical Therapy?
23.3 The Physical Therapist’s Documentation
23.4 Evidence in the Physical Therapy Record
23.5 The Physical Therapist as an Expert Witness
23.6 Summary

Chapter 24: Rehabilitation Records
Jane O’Rourke, MSN, RN, CNAA
24.1 Introduction
24.2 The Rehabilitation Team
24.3 Scope of Documentation
24.4 Summary

Chapter 25: Respiratory Care Records
Hilary J. Flanders, MPH, RN-BC, RRT
25.1 Introduction
25.2 Types of Patients Who May Require Respiratory Care
25.3 Professionals Who Provide Respiratory Care in the United States
25.4 Clinical Issues
25.5 Respiratory Equipment and Medications
25.6 Diagnostic Tests
25.7 Respiratory Diseases and Management Techniques
25.8 Summary

Chapter 26: Skin Trauma
Kelly A. Jaszarowski, MSN, RN, CNS, ANP, CWOCN
26.1 Introduction
26.2 Wounds
26.3 Burns
26.4 Pressure Ulcers
26.5 Incontinence
26.6 Ostomies
26.7 Summary

Chapter 27: Controversies in Skin Trauma
Steven Charles Castle, MD
27.1 Introduction
27.2 Surgical Wounds
27.3 Psychological Factors Associated with Skin Trauma
27.4 Overview of Wounds
27.5 Pressure Ulcers
27.6 Quality of Nursing Care and Documentation in Long-Term-Care Facilities
27.7 Controversies in the Use of Specialized Care for the Prevention and Treatment of Pressure Ulcers
27.8 Nutritional Support in Wound Healing
27.9 Summary

Appendices
Appendix A: Medical Terminology, Abbreviations, Acronyms, and Symbols
Ann M. Peterson, EdD, MSN, RN, CS, LNCC
Appendix B: Internet Resources
Appendix C: Textbook References
Appendix D: Glossary

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