Review of Medical Records- Not so simple

Posted by on Jan 12, 2011 in Blog, Legal Nurse Consultant, LNC

Anyone can review a medical record and create some sort of chronology.  But the real key is what does all that information mean?  The reviewer/consultant must be able to: Review AND understand the medical documentation, terminology, medical conditions and procedures. Identify and convey how the medical information impacts/affects pre-existing conditions.  Determine if the previous injuries or surgeries affect the current condition. Conclude if the mechanism of injury fits/correlates with the alleged diagnoses/conditions. WWW.MONTAUKPLAYHOUSE.ORG/WWW/ The records must be organized, reviewed, analyzed and on some level opined about.  The medical information is only useful when the attorney or insurance adjuster understands the importance of the information. I am currently reviewing a case for a law firm.  They requested a medical record review with chronology.  A paralegal could have generated a standard chronology AND a high-priced physician advisor could have rendered an opinion about relatedness or causality, but what about everything in between?  The information in the middle is equally, if not at times more, critical to a case.  There is so much more to a case than a timeline or answering a causality question. And….that’s where I come in!   Here are few points that my work product covered: Created a working chronology with clear, ongoing comments about the medical record information  Looked at the pre-existing conditions, pre-existing medications, prior injuries and surgeries and explained how or if any of these issues impacted the case  Provided detailed arguments for counsel based on medical facts/information so he could prepare/strategize for depositions/trial Identified missing records that were critical to the case Recognized subtle treatment discrepancies, treatment lapses and condition changes as seen on diagnostics These are just some of points that should be standard for any review. Make sure your medical legal reviewer is covering these points.  Could have a paralegal done some of this? Yes. Could have a physician done some of this? Yes. A comprehensive LNC report provides the client with a working roadmap on how to move forward.  I created a clear picture of the case from beginning to end  I identified holes in the record and helped to develop a strategy to achieve the client’s goals  Will I be working with a paralegal on this case? Yes. Will we need a physician at some point? Perhaps, but based on the LNC report we know the most appropriate specialty and what exactly we need from him. The bottom line – A COST EFFECTIVE comprehensive, detailed, concise and directional report was created to help counsel move...

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To Clot or Not?

Posted by on Jan 6, 2011 in Blog, Case Management, LNC, Nursing, RN

Over my many years as a RN I have had multiple patients on anticoagulation medications.  As a result I am very comfortable in administering the medications as prescribed by physicians. In addition, I have worked on cases involving anticoagulation both as a Case Manager and a LNC, yet the complications and dangers of working with such medications cannot be stated enough or go underemphasized. In all of these roles, there are some cardinal rules- Extreme care with ALL aspects of dosing/administration Regular medical follow up Careful blood level monitoring (PT/INR) Thorough patient/family education I recently read a blog post detailing information about anticoagulation, potential problems/complications and improvements within the medical arena.  Areas like patient education, pharmacy/pharmacist involvement, patient compliance, new delivery systems and overall management improvements are being addressed throughout the medical communities- all of which are improving patient quality and continuing to help save lives.   Highlights: An anticoagulant is a substance that prevents coagulation; that is, it stops blood from clotting Anticoagulants are administered in oral or parenteral (injection) forms. Examples heparin, Coumadin (warfarin)  Anticoagulation medicines play a huge role in clinical medicine and help to save lives on a daily basis. Close management of the medications is necessary, and mistakes involving too much or too little medication can lead to severe complications. Law suits involving anticoagulation issues are fairly common. Other medications (i.e. aspirin) and/or food (dark green vegetables) have anticoagulation properties, so potential drug interactions must be identified and/or monitored. Anticoagulation is literally a LIFESAVER, but it also carriers with it severe and sometimes deadly complications that are associated with too much OR too little medication.  Better things are on the horizon, but caution when using/taking the medications still...

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