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Category Archives: Medical records
Computerized medical records: two views
Computerized medical records offer many advantages and some disadvantages. In preparing to teach a preconference next week at the Academy of Medical Surgical Nurses annual meeting, I have been doing more reading about computerized records. We handle these records every … Continue reading
Top 10 tips for analyzing Emergency Department Records – Part 2
Personal injury attorneys frequently handle cases that involve injuries which require emergency department treatment. Here are 10 questions you should ask when you look at these records. Can’t read the records? Ask for our help. We have vast experience in … Continue reading
10 Top Tips for Analyzing Emergency Department Records Part 1
Personal injury attorneys frequently handle cases that involve injuries which require emergency department treatment. Here are 10 questions you should ask when you look at these records. Can’t read the records? Ask for our help. We have vast experience in … Continue reading
Posted in Emergency Medicine, Medical records
Tagged emergency department records, ER records
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Have you obtained ALL of the physician records?
Physician practice and clinic records can be pivotal in nursing or medical liability cases. These records may be obtained in the same way as hospital records. Nursing documentation in physician practices and clinics should follow guidelines for legally appropriate charting. … Continue reading
Nursing documentation: if you didn’t chart it you didn’t do it
“If you didn’t chart it you didn’t do it.” In the medical legal world, this expression engenders more fear in nurses than almost any other phrase as it is used to reiterate the importance of documentation. The phrase is also … Continue reading
Top 4 reasons why there is gold in nurses’ notes
1. Comprehension: Nursing documentation is often the key to understanding the events that spawn a nursing or medical malpractice claim. The medical record can refute or support the plaintiff’s or defendant’s version of events. 2. Screen cases: Careful scrutiny of … Continue reading
Specialty Documents in LTC – A Primer
Dana Jolly, BSN, RN, LNCC, Principal, Jolly Consulting, LLC & Legal Nurse Consulting Institute, LLC and co-presenter of an all new webinar on polishing your writing skills Don’t let a lack of clinical experience in a specific field to limit … Continue reading
Transparency and reporting medical errors? Not in Missouri
Hospital errors kill more people every year than car crashes, diabetes or pneumonia, according to federal government estimates. But Missouri hospitals don’t want people to know when and where these mistakes happen – and no law requires them to tell. … Continue reading
Posted in Medical records
Tagged reporting medical errors, transparency in healthcare
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New study identifies lack of improvement in health care
Temporal Trends in Rates of Patient Harm Resulting from Medical Care”, New England Journal of Medicine, 11/25/2010. Read at http://tinyurl.com/297884t This new study reviewed 2,341 patients’ records from stays at 10 North Carolina hospitals from 2002 to 2007. The reviewers … Continue reading
Computerized medical records and litigation
There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages. The fifth is the impact on litigation. Many facilities are also putting their policy and procedure manual “on line”. … Continue reading
