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Category Archives: Medical records
Computerized medical records – forensic issues Part 1
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 … Continue reading
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 … Continue reading
Computerized medical records – quality
There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages. The second is quality. Electronic medical records manipulate and display information in a way that no paper and pen … Continue reading
Computerized medical records – efficiency
There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages. The first is efficiency. The enormous amount of data that are collected about a person’s health can be stored … Continue reading
Pat Iyer’s 9 tips on detecting altered medical records Part 5
Examine logs or communication books kept at the nursing station of some nursing homes. I found a note in a nursing home communication book that stated, “When you recopy the nurses’ notes, leave enough room for the night shift to … Continue reading
Posted in Healthcare Risk Management, Legal nurse consulting, Medical errors, Medical malpractice, Medical records, Nursing malpractice, Tampering with evidence, Trial lawyer skills
Tagged altered medical records, altered records, spoliation of evidence, spoliation of medical records, tampering with medical records
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Pat Iyer’s 6 tips on detecting altered medical records part 4
Look for the “too good to be true” pattern of documentation. For example, the patient was steadily losing weight but supposedly consuming 100 percent of his 2000 calories per day diet. Note entries that are self-serving and needlessly explanatory of … Continue reading
Posted in Healthcare Risk Management, Legal nurse consulting, Medical errors, Medical malpractice, Medical records, Nursing malpractice, Tampering with evidence, Trial lawyer skills
Tagged altered medical records, altered records, spoliation of medical records, tampering with medical records
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Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 3
Examine handwriting to see if there are obvious changes in the appearance of the writing within an entry. Another thing to look for is a change in style. If notes are sloppily written and suddenly a page of neatly written … Continue reading
Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 2
Compare the nursery records generated at birth with those sent to the hospital to which the baby is transferred. Review the copies of hospital records found within a physician’s office records with those supplied by the hospital. In most hospitals, … Continue reading
Pat Iyer’s Dirty Dozen Tips for Detecting Altered Records Part 1
Determine if the entries are in correct sequences and the date is within the correct time frame. For example, a physician recopying an office note may inadvertently use the year that the change is being made, rather than the right … Continue reading
How Physical Therapists Chart – Based on a chapter by Gwen Simons PT, JD, OCS, FAAOMPT
The physical therapist is required by law to perform a physical therapy examination (sometimes referred to as an evaluation) on each patient on the first visit. The examination is divided into three steps: Taking the patient’s history Performing a systems … Continue reading
Posted in Damages, Medical records, Personal injury
Tagged phyiscal therapy, physical therapy charting
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