Six ways to avoid getting tripped up by medical records

Posted by on Nov 11, 2014 in Blog, Legal Nurse Consultant, Legal Nurse Consulting, LNC, Medical Conditions/Terminology Blog Series, Uncategorized

Continuity of care and information are critical when reviewing a medical record. Continuum of information, evaluations and treatments start with the initial injury and travel through the medical record. But what first started out as a nice straight line quickly becomes a bowl of spaghetti, with many nuanced twists and turns. It takes an expert’s eye and first-hand experience to follow these long , slippery strands. Here are six tips to help you avoid getting tangled up yourself: Look at each medical provider closely and on its own merit. Ask, does the information at the beginning of the record hold true at the end of the record? This is particularly important for Emergency Department records. (See earlier ED blogs). For example, is what was told to the ER triage nurse the same as what was told or documented by the physician? When a claimant or patient is seen by another provider, does the information about the injury/event/diagnosis remain constant and consistent or does it morph into something else? Think of a piece of paper torn in half. Can you line up the edges to recreate that one piece of paper? If information does not line up, then that should be a red flag for the attorney or adjuster that something — some crucial fact or piece of data — may be missing or even misrepresented. If you are reviewing an inpatient stay record, look closely at the change of shift documentation. Nurses report to other nurses when there is a shift change. Is the information documented by the receiving nurse the SAME as what had been noted earlier by the departing nurse? If not, that’s another red flag. When reviewing a diagnostic report, look at the reported diagnosis and ordering physician. Is this information consistent with other documentation? Sometimes you can determine that a new physician has been brought in on the case as that physician is the “ordering physician.” This is especially true for outpatient diagnostic studies. Remember: consistency and continuity are key. Look carefully at what the injured party is reporting/describing to each provider. Is it consistent or does it change or grow? The information should be fairly consistent and make sense in the context of the alleged event and throughout ongoing treatment documents. Follow the “Trauma Timeline” through the record. Look at timing, treatment and the associated responses. Ask, did something new or different appear long after the initial injury? If so, is it a secondary complication or truly a horse of a different color?? As you can see, this process can be daunting, especially for a non-medical person. That’s where LNC’s can help. We are used to following that slippery string of spaghetti. From receiving...

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Po-Ta-to… Po-TAh-to… Understanding professional terminology takes, well, a professional.

Posted by on May 25, 2014 in Blog, Legal Nurse Consultant, LNC, Medical Conditions/Terminology Blog Series, Uncategorized

by Neely L. Cotten, MSN, ACNP-BC While I was watching the nightly news a few evenings back, I cringed.  I watched as the manicured anchorwoman talked in depth of “two-type diabetes.”  As a healthcare provider, her misuse of medical terminology sounded like fingernails on a chalkboard.  I wanted to shake the television and yell “It’s type-two diabetes!  Type-two.” Then I calmed down. I remembered that it’s our job as professionals job to explain and educate the public when they step into our world.  When you and I explain and educate, we serve our patients and clients and members…physically, emotionally, financially and otherwise. We are immersed in pseudo-medical vernacular. It shows up in popular culture, our business life, and our casual speech.  Professional, technical dialects require training; lawyers, business persons, and physicians are just a few of the groups who use a daily language specific to their specialty. Case in point… A study was recently conducted to assess patients’ true comprehension of informed consent.  Informed consent is the process of obtaining permission to perform a medical intervention on a patient.  The healthcare provider must review the risks, benefits, and timeline of the procedure by speaking one-on-one with the patient.  Permission can only be granted by an individual with the capacity to comprehend what’s happening. The majority of consent documents for medical diagnosis and treatment, however, are written at a reading level above that of the majority of the US population.  Despite granting their informed consent, the study showed that patients are repeating medical terms, agreeing to treatments and accepting diagnoses they do not understand. And despite this documented effort to improve patient education, patients reported feelings of stress, confusion and anxiety prior to their medical treatment. So, as a public service… Rather than merely curse the darkness, I’ve compiled a short list of common medical terms you may (or may not) think you understand along with a brief definition! Hypertension – High blood pressure Hypotension – Low blood pressure Arrythmia – Irregular heart beat Cardiovascular – Pertaining to the heart and blood vessels Myocardial Infarction – Heart attack Diuretic – A medication used to help the body dispose of excess fluid Embolism – The blockage of blood flow in the vessels caused by a blood clot; this means oxygen and other blood nutrients cannot reach the tissues supplied by those vessels. Diabetes – A predisposed state of high blood glucose (sugar) because the body cannot create enough insulin to regulate the levels Type 1 Diabetes – A genetic condition where the body does not create its own insulin, causing very high blood glucose levels Type 2 Diabetes – An acquired condition where the body becomes resistant to its own insulin...

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Delaying Treatment & Its Impact

Posted by on May 11, 2014 in Blog, Legal Nurse Consultant, LNC, Medical Conditions/Terminology Blog Series, Uncategorized, WC

By Debra West, RN, BSN, CCM, LNC Legal nurse consultants frequently find that a claimant has delayed treatment. Sometimes the delay may be only days, but many times the delay extends into weeks or months after the injury. The problem Delayed treatment makes it difficult to establish what injuries, if any, are causally related to the incident.  With any gap in treatment, we cannot reliably know a claimant’s clinical presentation immediately after an injury, which is key to assessing the legitimacy of an insurance claim. The medical perspective Without a complete understanding of the claimant immediately post injury, there is no way to unequivocally relate subjective complaints reported well after an injury. If the claimant is not evaluated within a reasonable timeframe after the incident, any bruising, contusions or lacerations which may have occurred at the time of injury would likely have resolved, leaving it impossible to assess for signs of direct trauma. The bottom line As legal nurse consultants, we are asked to review medical records and render an opinion if the alleged injuries are consistent with the Mechanism of Injury.  While we may not be able to directly relate subjective complaints reported weeks or months after the injury, what we can do is provide the claims handler with the necessary information why the delay or absence of medical care make it impossible to relate the complaints with the incident. Debra West, RN, BSN,CCM, LNC is a legal nurse consultant with MKCMedical Management.  Contact Debra at or...

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