Expertise
How to Document an IME
You may find it unnerving and insurmountable to take notes the first time you are asked to document an IME. This is called an independent medical exam, insurance medical exam or a defense medical exam. Here are tips on how to document an IME. The exam is required by the insurance company to prove or…
Read MoreCopying and Pasting in Medical Records: How to Recognize It
As a legal nurse consultant, you are in an ideal position to detect copying and pasting in medical records. This is what you might see: A staff nurse copies the note she wrote the previous day. Or she copies the note written by the previous shift. The attending physician copies a progress note he wrote…
Read MoreLegal Nurse Consultant’s Role in Preparing Demonstrative Evidence
Nurses think visually, a skill that helps legal nurse consultant working with attorneys in preparing demonstrative evidence. How do you use this skill with litigation? Although demonstrative evidence usually refers to exhibits created for use with mediations or trials, it can be used in reports or settlement brochures as well. Preparing Demonstrative Evidence: Begin with…
Read MoreNursing Expert Witness Reports: 10 Tips for Presenting Facts and Opinions
I have written or read thousands of nursing expert witness reports over the last 26 years. Your nursing expert witness report will be read by the attorneys on both sides, claims adjusters, the risk manager, the judge, and opposing experts. You must be able to craft a powerful nursing expert witness report in order to…
Read MoreEmergency Department Medical Records Part 2
Legal nurse consultants play a vital role in helping attorneys understand medical records. Here are some of the things you may find in emergency department medical records. Read part 1 for more tips about emergency department medical records. What to look for in emergency department medical records • Was there a positive alcohol smell noted?…
Read MorePersonal Injury Medical Records – What to Look For
Physician office records may hold the keys for analyzing personal injury cases. These personal injury medical records can make or break a plaintiff’s case. It is crucial that you as the legal nurse consultant are able to read and decipher these records in a personal injury case. Look for these pieces of information. Personal Injury…
Read MoreMissing Medical Records
How do you know as a legal nurse consultant that there are missing medical records? Are the medical records 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 LNCs to detect there are missing medical records. This often…
Read More3 Ways to Pitch Your Value to Attorneys: Medical Records
Anyone can read a medical record. Or can they? If everyone could read medical records, the attorney would not need someone with a 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…
Read MoreComputer Provider Order Entry Part 2
Legal 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 MoreMissing Documentation
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…
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