This article was originally published in the Summer 2006 issue (vol 17:3, p. 23-24) of The Journal of Legal Nurse Consulting, the official journal of the American Association of Legal Nurse Consultants (www.aalnc.org). Reprinted with permission.
Medical Legal Aspects of Medical Records
Reviewed by Beth C. Diehl-Svrjcek, MS RN CCR NNP CCM LNCC
Medical Legal Aspects of Medical Records
Patricia lyer, MSN RN LNCC, Barbara J.Levin, BSN RN ONC LNCC &
Mary Ann Shea, JD BS RN
Publisher: Lawyers and Judges Publishing Company, Inc.
ISBN: 13: 978-1-930056-75-6 (hardcover)
Number of Pages: 957
Cost: $149.00, Hardback
Upon turning the initial pages of this textbook, one becomes acutely aware that this publication is an incredible compilation of information essential to the practice of any legal nurse consultant (LNC). Penned by authors well-known for their extensive involvement and long term commitment to legal nurse consulting, Patricia lyer, Barbara Levin, and Mary Ann Shea, the book has exceptional depth and breadth. It provides a structural foundation for medical legal record review and analysis that encompasses regulatory issues and multiple clinical specialty areas.
In addition, the reader is privy to the shared knowledge and clinical expertise of 50 contributing authors. These authors represent various disciplines: nursing, law, emergency medicine technology, medicine, pharmacy, chiropractic, dentistry, forensic document examination, and epidemiology. Given the vast array of contributors, the reader may surmise that the flow of the text could be somewhat erratic; however, that is not the case. The authors have clearly provided a uniform concept and context upon which the book is written.
This text is architecturally sound, with an outlay of information that proceeds in a methodical fashion from fundamental principles of medical record structure/format to a subsequent detailed discussion of clinical specialty areas and forensics. Given that the medical record is the keystone for clinical practice, one cannot underestimate the importance of being thoroughly familiar with how best to interpret, analyze, scrutinize, and reference all of the crucial information contained within such a document. This formidable task is simplified by referencing “Medical Legal Aspects of Medical Records.”
The book is divided into four major parts that independently cover the essentials of all medical legal aspects of documentation. The four parts are:
• Part I: Overview
• Part II: Outpatient Specialty Areas
• Part III: Specialty Areas
• Part IV: Forensic Aspects
Interestingly, each chapter leads off with a detailed synopsis referencing specific points of discussion so that the reader can quickly seek desired information. Throughout the text, tables, illustrations, photographs, and graphic templates of documents serve as practical examples. The frequent “Tips” on virtually every page are refreshing and effective anecdotes to highlight salient pieces of information. Chapter “Endnotes” provide the reader with an alternate listing of resources, if further exploration is needed.
Part I, which consists of fourteen chapters, sets the stage for the remaining three parts by reviewing some aspects of medical record acquisition, organization, and preservation. LNCs learned these fundamentals in nursing school, but given the sweeping changes that have impacted health care documentation systems and medical record technology over the past decades, this is an excellent refresher. All aspects of the nursing process are thoroughly outlined, with a review of the types of charting systems currently utilized nationwide in health care settings, i.e. narrative, SOAP, PIE, FOCUS, FACT, or charting by exception. With the push toward computerized medical records per the 1991 Institute of Medicine report, this text examines the present status of this endeavor, focusing on advantages and disadvantages of computer-based systems as the transition to paperless technology continues.
For the LNC who is not as familiar with billing and coding, chapter 10 provides a comprehensive tutorial for either the novice or experienced LNC in terms of bill generation, coding references, and fraudulent billing. The final portion of Part I deals with regulatory influences as they impact medical records, including, but not limited to, the Health Insurance Portability and Accountability Act (HIPAA), The Joint Commission for Accreditation of Healthcare Organizations UCAHO), and National Patient Safety Goals. Standards initiatives, primarily for patient safety with their concurrent documentation requirements, will serve as a welcomed reference to the LNC involved in evaluating a malpractice case resulting from a violation of patient safety. Presuit use of medical records in chapter 13 is an important component, as the LNC may need to interface with hospital risk management personnel and navigate the sensitive issues associated with incident reports. The final chapter on attorney use of medical records provides the reader with a greater understanding and appreciation for what is truly required from a medical record standpoint for an attorney to successfully weigh the pros and cons of a particular case.
Part Il is a relatively abbreviated section of the book, which consists of six chapters and deals specifically with outpatient specialty areas. Documentation regarding chiropractic care, acupuncture, dental procedures, home care, and ophthalmology are examined. Although these areas are not as frequently cited in medical litigation as some other clinical areas, for an LNC dealing with such, these chapters are a wonderful resource for those individuals with minimal baseline knowledge.
In addition, this section has two chapters that address topics often entangled in the litigation process: the office based medical record and the independent medical examination (IME). The IME chapter delineates the step-by-step process of an IME, culminating with final impressions and professional opinions regarding the IME. The section on office based medical records was very helpful. As many LNCs are aware, office based verbal communication may not be adequately corroborated with written documentation — and may even serve as the wavering domino leading to an unfortunate cascade of events resulting in medical malpractice litigation.
Part III, chapters 21 through 38, deal specifically with clinical specialty areas. This is the “meat and potatoes” for LNCs who are routinely involved in medical malpractice litigation. These chapters address many high-volume, high-risk areas of clinical practice, e.g. critical care, emergency department, intravenous therapy, obstetrics, orthopedics, pediatrics, skin trauma, medication administration, and psychiatric care. The reader will benefit tremendously from the expertise and experience of each contributing author. If an LNC is already clinically experienced in one of these particular fields, it is likely that the information contained within the chapter will reinforce an existing knowledge base. For the LNC without clinical expertise in one or a number of these designated clinical areas, the chapters will provide an excellent starting point to explore pertinent definitions, patient care interventions, treatment complications, and practice standards.
Part IV of the text explores forensic aspects of care. Although any LNC may encounter altered medical records or utilize a forensic document examiner, for those involved in criminal prosecutions, chapter 41 wilI be highly beneficial. A detailed discussion of forensic evidence from sexual assaults, gunshot wounds, auto accidents, and poisonings provide examples. The final chapter of the book addresses autopsy reports, which may be an integral component of malpractice, product liability, or toxic tort litigation.
The book concludes with an appendix of medical terminology, Internet resources, textbook references, and a glossary. These four subcomponents, as evaluated separately from the main text, are excellent as a stand-alone reference for the practicing legal nurse consultant.
In summary, authors lyer, Levin, and Shea have provided the legal and nursing community a comprehensive and worthwhile resource for medical record examination. Whatever your level of competence in legal nurse consulting practice, whether novice or seasoned expert, this publication will be as valuable addition to your reference library.
Beth C. Diehl-Svrjcek, MS RN CCR NNP CCM LNCC, is a Neonatal Nurse Practitioner at Johns Hopkins Hospital in Baltimore, Maryland, where she functions as a Transport Nurse for the Maryland Regional Neonatal Transport Program. She has miore than 27 years of combined experience in adult critical care, neonatal intensive care, pediatrics, post acute pediatrics, case management, nursing staff development, utililzation review, and nursing supervision. She maintains an independent LNC practice specializing in medical malpractice for plaintiff and defense litigation. She has been used as an Expert Witness since 1988. A former board member of the Greater Baltimore Area Chapter of AALNC, she maintains certifications as a critical care nurse, case manager, and legal nurse consultant.