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Detection of Tampering with Medical Records Toolkit
For
Plaintiff Attorneys, Legal Nurse Consultants, and
Paralegals
Patricia
W. Iyer, M.S.N, RN, LNCC
96
pages
2005, Med
League
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Special offer:
Buy this product and either Medication
Errors video or Nursing Home
Liability video and save $20.00!
Table of Contents
Whether you are an attorney or legal nurse
consultant, you will gain from reading this toolkit. Expert
Patricia Iyer presents
information on detection of tampering with medical
records in a practical manner. You’will learn the
legal implications of tampering andhow to detect tampering.
Included are many actual examples of altered records. (See
also our product for administrators,
risk managers, and defense attorneys.)
The 96 pages of content cover these topics:
- substandard
charting
- suspicious
charting
- definitions
of spoliation
-
spoliation inference
-
implications of spoliation
- organizing
medical records
- techniques
for tampering with medical records
- detection
of tampering
- strategic
decisions
- defense
of spoliation claims
Also included are three checklists:
- Is there reason to believe that the medical record may
have been tampered with?
- A blueprint for organizing medical records
- Strategies for detection of tampering with medical records
as well as 35 slides of examples
of altered records and descriptions of almost 30
legal cases involving tampered records.
The material in this toolkit has been assembled
over years by an experienced legal nurse consultant and
author of two chapters on tampering with medical records:
Patricia Iyer, Nursing
Home Litigation: Investigation and Case Preparation,
Second Edition, 2006.
Patricia Iyer, Barbara
Levin, and Mary Ann Shea, Medical
Legal Aspects of Medical Records, 2006.
Table
of Contents
1.
Introduction
2. Substandard Charting
Incomplete charting • Untimely charting •
Illegible handwriting • Incorrect charting
3. Suspicious Charting
Detailed addenda • Duplicate information
4. Definitions of Spoliation
5. Spoliation Inference
6. Implications of Spoliation
Effect on the case • Jury charge •
Effect on the healthcare provider: Insurance coverage, Regulatory
agencies and privileges, Criminal/civil offenses •
Tampering by attorneys • Remedies for the person harmed
by spoliation
7. Organizing Medical Records
Compiling records • Other documents and
items to review
8. Techniques for Tampering With Medical Records
Adding to an existing record at a later date •
Placing inaccurate information into the record • Omitting
significant information • Changing numbers •
Rewriting the record • Destroying records •
Adding to someone else's notes
9. Detection of Tampering
Incident report • Examples of allegations: Pressure
ulcers, Malnutrition and dehydration, Physical and sexual
assault, Falls and fractures, Elopement, Birth trauma, Surgical
errors
10. Strategic Decisions
Document examiners • Discovery requests • Use
of interrogatories
11. Defense of Spoliation Claims
Elements of proof • Proactive approach with defendants
• Credibility
12. Summary
References
Checklist 1: Is There Reason To Believe That The Medical
Record May Have Been Tampered With?
Checklist 2: A Blueprint for Organizing Records
Checklist 3: Strategies for Detection of Tampering
Related
products:
With Patricia Iyer as author,
editor, or contributor
Detection
of Tampering with Medical Records Toolkit for Administrators,
Risk Managers, and Defense Attorneys
Essentials
of Medical Record Analysis
Falls
Handbook
Guide
for Assessing Hospital Liability: A Former CEO's Perspective
Medical
Legal Aspects of Medical Records
Medication Errors video
Medication Errors Toolkit
Med
League DVD: Patricia Iyer's Television Appearances
Nursing
Home Liability video
Nursing
Home Liability Toolkit
Nursing
Home Litigation: Investigation and Case Preparation
Paralysis
from a Medical Error
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