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Detection of Tampering with Medical Records Toolkit
For
Administrators, Risk Managers, and Defense Attorneys
Patricia
W. Iyer, MSN, RN, LNCC
85 pages (48 pages plus
37 slides)
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
Healthcare administrators and risk managers know
the implications of tampering with medical records, but do their
staff? Tampering still goes on. In this toolkit, Patricia
Iyer enables the healthcare administrator or risk manager
to use concrete techniques to identify tampering with medical
records so that this concern is uncovered early in management
of the consequences of an incident. Information on detection of
tampering with medical records is presented in a practical manner.
(See also our product for plaintiff
attorneys, legal nurse consultants, and paralegals.)
The 48 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 two checklists:
- Is there reason to believe that the medical record may have
been tampered with?
- Strategies for detection of tampering with medical records
as well as 37 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: Strategies for Detection of Tampering
Related
products:
With Patricia Iyer as author,
editor, or contributor
Detection
of Tampering with Medical Records Toolkit for Plaintiff Attorneys,
Legal Nurse Consultants, and Paralegals
Essentials
of Medical Record Analysis
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
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