Medical Records
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. Pen and paper medical records are plagued by illegible handwriting along with non-standardized and dangerous abbreviations, which can lead to medical errors. Electronic records are legible and are programmed to use only approved terminology…
Read MoreComputerized medical records – forensic issues
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…
Read MoreComputerized medical records problems
Computerized medical records are here to stay. Not perfect, but better than handwritten records. This method of recording information about a patient offers many advantages but also some significant disadvantages. Computerized medical records have drawbacks that affect the legal nurse consultant’s ability to analyze medical records. Drawbacks of computerized medical records Electronic health records can…
Read MoreComputerized medical records and litigation
Attorneys and legal nurse consultants spend much time poring over computerized medical records and litigation intensifies the need to understand these records. There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages in litigation. Computerization of documentation provides some benefits for those involved in…
Read More“If you didn’t chart it, you didn’t do it”, Part 4: Common Medical Record Deficiencies
Nursing homes are affected by many challenges, many of which directly affect the quality of care and allegations of nursing home negligence. The challenges were highlighted by speakers at Preventing and Defending Long Term Care Litigation at The Conrad in Miami. Pat Iyer moderated a panel of defense and plaintiff attorneys and another legal nurse…
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