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. How do you pitch your value to attorneys about medical record analysis? This is what an LNC offers: the keys to medical record analysis […]
Read MoreSometimes I feel a little like a dinosaur. I like paper medical records. I like them printed out, organized and ready for my review as a legal nurse consultant. Medical record review: which is faster? Although I received PDFs of medical records, I used them to print out paper records. Using preprinted medical record tabs, […]
Read MoreLegal nurse consultants are increasingly receiving electronic health records for analysis. How do these records help patients and providers? How does computer provider order entry affect medical care? In part 1, I specifically addressed the savings of computer provider order entry. 1. Facilities using EHRs and computer provider order entry could gain greater market share […]
Read MoreLegal nurse consultants increasingly receive electronic health records (EHRs) for analysis. How do EHRs save money and lives? What specifically are the advantages of computer provider order entry? 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 […]
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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 there is missing documentation. We don’t always […]
Read MoreNew York became the 18th state to no longer requireexperienced 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 even more independent. Nurse practitioners’ expanding liability accompanies their expanding role. As patients receive insurance as a […]
Read MoreIn Part 1, I explained how you can spot substandard charting. Suspicious charting goes one step further to raise concern about the medical records. Substandard Charting or Fraudulent Charting Trouble: 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 […]
Read MoreThe 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 MoreLegal 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 MoreRed 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 […]
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