Copy-and-Paste in Medical Records: Prevalence, Risks, and How to Spot It Today

doctor surrounded by paper

Electronic health records (EHRs) have revolutionized healthcare documentation, but they come with a copy-and-paste convenience that is a double-edged sword. Copying forward prior notes can save time for busy clinicians, yet overuse of this shortcut (“cloning” documentation) leads to widespread concerns in patient safety, care quality, and legal liability. Legal nurse consultants, attorneys, and healthcare…

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Tampering with Medical Records

a magnifying glass

Identifying fraudulent medical records is essential for legal nurse consultants and attorneys alike. It is one of the most critical tasks legal nurse consultants may perform and provides us with the opportunity to use our detailed-oriented skills as we detect tampering with medical records. The discovery of fraudulent medical records changes the entire complexion of…

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Charting Omissions: Not Documented, Not Done

Charting omissions

The cross-examination of the nurse defendant begins with these questions: “What is the purpose of clinical documentation?” “What are the responsibilities of the professional nurse to record in the medical records?” “I direct your attention to the neurovascular flowsheet for 10-12-23. We’ve established that you were taking care of the patient on that date, correct?”…

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Sexual Abuse Cases in Nursing Homes: Hidden Challenges

woman holding fists to face

Does the story behind sexual abuse cases help or harm your case? LNCs and attorney focus on the critical intricacies of nursing home abuse cases, as detailed in the chapter Torn Veils of Protection: The Hidden Challenges of Sexual Abuse Cases in Nursing Homes in Medical Record Analysis, volume 3.   Deneene Bradford emphasizes the…

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Mechanisms of Injury in Motor Vehicle Collisions

large truck crashed into a number of cars and 4 people were killed

Mechanisms of Injury in Motor Vehicle Collisions Mechanisms of injury refers to how traumatic forces affect the human body, causing injury. How can LNCs help attorneys with motor vehicle crash cases? You will need an understanding of the various forces exerted upon the vehicles and occupants (humans riding in the vehicle) in multiple configurations of…

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Medical Record Analysis: A Guide for Attorneys by Expert LNCs

  Medical Record Analysis – What is it? How do you decipher the often complex issues associated with medical cases? How do you make sense of often indecipherable medical records? And how do you tease apart the liability of these cases? Have you felt frustrated by the sheer amount of medical details involved in litigation?…

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DME Report Writing: A Comparative Analysis

Quiet scene of mid aged patient and doctor sitting in medical room

DME Report Writing In Defense Medical Exams (DMEs), the significance of the reports prepared by the examining physician and the Legal Nurse Consultant (LNC) who observed the exam cannot be overstated. These reports serve as crucial documentation that can significantly influence the outcome of legal proceedings. Understanding how these reports coincide or differ is essential…

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Dumpster Diving Difficulties

a picture of a dumpster

I couldn’t believe what I heard. “The records you just threw away? They are the only copy that exists.” The defense attorney hired my LNC company to create summaries and other work products for a case involving multidistrict litigation. The plaintiffs alleged their back injuries were due to defective pedicle plates and screws. Over 100…

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Your LNC Report’s Appearance

Your LNC report’s appearance is critical to providing what your client needs. Let’s look at how you can successfully create and present your LNC report. Join me in an aspect of macroscopic editing: finetuning the overall look of the work product. The recommendations below, while specifically written with reports in mind, can apply to any…

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