Medical Legal Aspects of Medical Records, Second Edition (Volume I)

(Text exerpted from review.) Upon turning the initial pages of this textbook, one becomes acutely aware that this publication is an incredible compilation of information essential to the practice of any legal nurse consultant (LNC). Penned by authors well-known for their extensive involvement and long term commitment to legal nurse consulting, Patricia Iyer, Barbara Levin, and Mary Ann Shea, the book had exceptional depth and breadth. It provides a structural foundation for medial legal record review and analysis that encompasses regulatory issues and multiple clinical specialty areas. In addition the reader is privy to the shared knowledge and clinical expertise of 50 contributing authors. These authors represent various disciplines: nursing, law, emergency medicine technology, medicine, pharmacy, chiropractic, dentistry, forensic document examination, and epidemiology. Given the vast array of contributors, the reader may surmise that the flow of the text could be somewhat erratic; however this is not the case. The authors have clearly provided a uniform concept and context upon which the book is written. This text is architecturally sound, with an outlay of information that proceeds in a methodical fashion from fundamental principles of medical record structure/format to a subsequent detailed discussion of clinical specialty areas and forensics. Given that the medical record is the keystone for clinical practice, one cannot underestimate the importance of being thoroughly familiar with how to best interpret, analyze, scrutinize, and reference all of the crucial information contained within such a document. This formidable task is simplified by referencing "Medical Legal Aspects of Medical Records". The book is divided into four major parts that independently cover the essentials of all medical legal aspects of documentation. The four parts are: Part I: Overview; Part II: Outpatient Specialty Areas; Part III: Specialty Areas; Part IV: Forensic Aspects; Interestingly, each chapter leads off with a detailed synopsis referencing specific points of discussion so that the reader can quickly seek the desired information. Throughout the text, tables, illustrations, photographs, and graphic templates of documents serve as practical examples. The frequent "Tips" on virtually every page are refreshing and effective anecdotes to highlight salient pieces for information. Chapter "Endnotes" provide the reader with an alternate listing of resources, if further exploration is needed. (review truncated here) The book concludes with an appendix of medical terminology, Internet resources, textbook references, and a glossary. These four subcomponents, as evaluated separately from the main text are excellent as a stand-alone reference for the practicing legal nurse consultant. In summary, authors Iyer, Levin and Shea have provided the legal and nursing community a comprehensive and worthwhile resource for medical record examination. Whatever your level of competence in legal nurse consulting practice, whether novice or seasoned expert, this publication will be a valuable addition to your reference library.