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Medical Legal Aspects of Medical Records - Lawyers & Judges Publishing Company, Inc.

Medical Legal Aspects of Medical Records

$ 159.00

  • Author: Patricia W. Iyer, Barbara Levin, Mary Ann Shea
  • ISBN 10: 1-930056-75-3
  • ISBN 13: 978-1-930056-75-6
  • Copyright Date Ed: January 2006
  • Pages: 976 pages
  • Binding Information: Hardcover
  • Size: 8.5 ✕ 11 Inches (US)

Use this book to get a comprehensive overview of the medical records process. In any health care situation, records are made, and each situation presents its own unique aspects and challenges. This book covers most medical and hospital areas of specialty, and also includes chapters on dentistry, chiropractic care, nursing homes, medications and home care. It also covers forensic issues in medical records, including examination of records and medical records obtained as part of forensic examination or autopsies.

Recent changes in legislation and technology have also changed the medical records process. The authors have designed this work to give extensive information on the HIPPA policies, standards initiatives, legal use of records, billing and coding, and computerization of records and record keeping systems and how they apply in forensic situations.This book is exceptionally valuable to all those in the legal profession or in law enforcement who deal with medical records on a regular basis.

Topics Include

  • Generation and preservation of medical records
  • Legal aspects of charting
  • Creation and maintenance of records in the nursing process
  • Charting systems
  • Computerized records
  • Billing and coding
  • HIPPA regulations
  • Standards Initiatives in medical records
  • Obtaining, organizing and analyzing records
  • Inpatient and outpatient specialty areas
  • Tampering with medical records
  • Forensic and autopsy records
  • Forensic examination of medical records
  • Attorney use of medical records

Table of Contents


Part One : Overview

Chapter 1: Generating and Preserving Medical Records
Definition and Purposes of the Medical Record
HIPAA and Medical Records: Administrative Simplification, Privacy, and Confidentiality
Privacy and Confidentiality
The Field of Health Information Management
Ownership of the Medical Record
Standards of Record-Keeping and Patient Care
Retention of Medical Records
Storage and Destruction of Old Medical Records
Additional or Supplemental Medical Records that may Exist Outside the Main Chart

Chapter 2: Legal Aspects of Charting
Timing of Charting
Format of Charting
Content of Charting

Chapter 3: Obtaining and Organizing Medical Records
Who Asks for the Records
What Records to Obtain
Medical malpractice cases
When to Ask for Records
How to Request Records and Other Information
Initial Intake of Records
Ensuring Records are Complete
Organizing Hospital Records
Organizing Rehabilitation Facility Records
Organizing Nursing Home Records
Organizing Physician Office Records
Organizing Ambulatory Care Records
Deciphering Records
Handling of Records

Chapter 4: Analyzing Medical Records
Analysis of Medical Records
Review of Personal Injury Records

Chapter 5: The Nursing Process: Overview of Documentation and Assessment
Overview of Documentation
Why Do Nurses Document?
Societal Factors Affecting Nursing Documentation
Trends in Charting
Documenting Assessment
Initial Database: Admission Assessment
Priority Assessment Issues
Advance Directives
Format for Admission Assessment Forms

Chapter 6: The Nursing Process: Nursing Diagnosis and Planning
Components of the Planning Process
Care Planning
Case Management
Documentation of Discharge Planning
Documentation of Planning for Patient Education

Chapter 7: The Nursing Process: Implementation and Evaluation
Documentation of Implementation
Safe and Timely Care
Implementation of the Plan
Evidence-based Interventions
Documentation of Referrals
Documentation of Evaluation
Documentation of Patient Education
Impaired Critical Thinking

Chapter 8: Charting Systems
Source-Oriented Charting
Narrative Charting
Problem-Oriented Charting (SOAP)
PIE Charting
Focus Charting®
FACT charting

Chapter 9: Computerized Medical Records
The Paper Chart
Use of Computers to Prepare Medical Records
Definitions of Computerized Medical Records
Status of Computerized Medical Records
Advantages and Disadvantages of Computerized Records
Bedside Terminals
Barriers to the Introduction of Nursing Information Systems
Implementation Challenges

Chapter 10: Billing and Coding
Value of Bill Review in Legal Setting
Basics of Medical Billing
Coding Responsibilities
Generation of Bills
Fraudulent Billing
Miscellaneous Issues

Chapter 11: Health Insurance Portability and Accountability Act (HIPAA)
History of HIPAA
Who is Regulated by HIPAA?
How HIPAA Impacts Medical, Nursing, and
Legal Arenas
Frequently Asked Questions About HIPAA
The Effect of HIPAA on Healthcare Providers and Law Firms
Privacy Issues
HIPAA Case Study
The Next Phase: Security Rules, Transaction and Code Set Standards, and Identifier Standards

Chapter 12: Standards Initiatives and Medical Records
The Current Healthcare Environment
The Joint Commission
The Joint Commission Survey Process
New Spotlight on Safety
National Patient Safety Goals
Improve the Accuracy of Patient Identification
The Effectiveness of Communication among Caregivers
Improve the Safety of Using High-Alert Medications
Eliminate Wrong-Site, Wrong-Patient, Wrong-Procedure Surgery
Improve the Safety of Using Infusion Pumps
Improve the Effectiveness of Clinical Alarm Systems
Reduce the Risk of Healthcare-Acquired Infections
Accurately and Completely Reconcile Medications across the Continuum of Care
Reduce the Risk of Patient Harm Resulting from Falls
The Leap Frog Group
Facility Documentation of
2005–2006 JCAHO Patient Safety Goals
National Quality Foundation Safe Practices

Chapter 13: Presuit Use of Medical Records
Reporting to Risk Management
Confidentiality of Incident Reports
Regulatory Standards
Sequestering Records
The Record Is What the Record Is
Potentially Compensable Events (PCEs)
Expert Witnesses
Reviewing the Medical Record
Insurance Carrier’s Involvement

Chapter 14: Attorney Use of Medical Records
Are the Relevant Records Complete?
History of Injury
Use of Medical Records
Analysis of Medical Records
Communicating with the Physician
Battle of the Titans, or How to Play David to the Insurance Carrier’s Goliath


Part Two: Outpatient Specialty Areas

Chapter 15: Chiropractic and Acupuncture Records
Goals of Care
Phases of Musculoskeletal Healing
Evaluation Protocols
Scope of Practice
Case Management
Standards of Care

Chapter 16: Dental Records
Background of Dentistry—Terminology
Extent of Dental Records
Disorders of Dental/Oral and Adjacent Structures
Dental Procedures/Treatments
Complications of Treatment
Documentation Practices
Use of a Dental Expert Witness

Chapter 17: Home Care Records
What Is Home Care?
Documentation in Home Care
Risks in Home Care
At-Risk and Non-Compliant Client
Home Care Cases
Recommendations for Reviewing the HomenCare Record

Chapter 18: Independent Medical Examination
Definition of an Independent Medical Examination
Components of a Thorough IME
Choice of an IME Physician
Differing Legal Perspectives on IMEs and Caveats
Scheduling an IME or Record Review
Structure of the Independent Medical Examination and Report
Review of Medical Records
Medical /Legal Controversies
Impressions and Professional Opinions
Role of the AMA Guides

Chapter 19:Office-Based Medical Records
Paper-Based Systems
Sections of Information Found in the Office Records Related to the Patient
Electronic Medical Records
Governing Organizations’ Documentation Guidelines
Physician Notes
Referrals or Consultations
How to Evaluate Office Medical Records
Is the Physician the Only Examiner?
Is There Office Nurse Documentation?
Does the Office Have a Protocol for Communicating Test Results?
How Does the Office Handle Phone Call Documentation?
Is There Documentation of Referral When Necessary?
Are There Red Flags Present in the Medical Record?
Patient Behavior

Chapter 20: Ophthalmology Records
Providers of Eye Care
Visual Acuity
Clinical Examinations s
Eye Symbols and Abbreviations
Refractive Errors
Ocular Structures
Disease States


Part Three: Specialty Areas

Chapter 21: Critical Care Records
Introduction to Critical Care Nursing
Types of Units
Standards of Critical Care Nursing
The Practice of Critical Care Medicine and Nursing
Documentation Issues
Types of Records and Systems
Use of Computerized Records
The Bedside Flow Sheet
Physician Documentation
Comparison of Records by Type of Institution—“Magnet” Status
Special Circumstances Encountered in Critical Care
Sources of Liability
Critical Care Flow Sheet—Thomas Jefferson University Hospital (used with permission)
Critical Care Flow Sheet—Cooper University Hospital (used with permission)

Chapter 22: Diagnostic Testing
Diagnostic Tests Involving Blood Work
Imaging Tests
Testing in Cardiology

Chapter 23: Emergency Medical Services Records
History and Development of EMS Systems
Types of Services
EMS Certifications
Types of Patient Transports
Transport and Crew Responsibilities
Medical Direction
Refusal of care
Do Not Resuscitate
Controlled Substances
Termination of Resuscitation in the Field

Chapter 24: Emergency Department Records
The Triage Process
Documentation of Triage and Treatment
Diagnosis (DX)
Patient Management
The Trauma Patient
Documentation of Patient Management
The Most Common Cause of Low Blood Pressure or Shock in a Trauma Patient Is Due to Blood Loss until Proven Otherwise
Management and Documentation of the Intoxicated Patient

Chapter 25: Intravenous Therapy Records
Peripheral Vascular Access Devices
Central Venous Access Devices
Site Monitoring Documentation
Legal Issues
Vascular Access Device Complications

Chapter 26: Nursing Home Records
Long-Term-Care Diversity
Subacute Care
The Nursing Process
Errors in Carrying Out the Nursing Process
The Importance and Purpose of Documentation
Regulations Pertaining to Medical Records
Overview of the Components of the Long-Term-Care Record
Admission and Care Planning Documents
Nursing Notes
Additional Nursing Documentation
Physician Documentation
Medicare Documentation
Discharge Documentation
Careless Documentation

Chapter 27: Medical Surgical Records
Respiratory System
Cardiovascular System
Neurological System
Renal System
Musculoskeletal System I
ntegumentary System
Endocrine System
Gastrointestinal System

Chapter 28: Medication Records
Overview of Pharmacy Practice
Pharmacists’ Roles and Responsibilities
Medication Related Records
Legal Considerations

Chapter 29: Obstetrical Records
Health History/Initial Pregnancy Profile
Estimating the Date of Birth
Prenatal Flow Sheet
Prenatal Testing
Intrapartum Care
Electronic Fetal Monitoring
Non-Reassuring Fetal Heart Rate Patterns
Pitocin Induction and Augmentation
Analgesia and Anesthesia
Cesarean Section
Vaginal Birth after Cesarean (VBAC)
Labor and Delivery Summary
Complications in Pregnancy
Anesthesia Record
Operative Record
Post-Anesthesia Care Unit (PACU)
Computerized Charting
Commonly Used Obstetrical Abbreviations

Chapter 30:Orthopaedic Records
Orthopaedic Definitions and Terminology
Traumatic Injuries
Essential Elements of the Musculoskeletal
Trauma Patient’s Medical Record
Elective Orthopaedic Procedures
Essential Elements of the Elective Orthopaedic Patient’s Medical Record
Orthopaedic Complications
Nursing Care Plans

Chapter 31: Pain Assessment and Management
National Guidelines for Pain Management 606
Elements of Pain Assessment
Pain Instruments
Commonly Used Pain Medications
Specialty Pain Assessment and Documentation

Chapter 32: Pediatric
Basic Tips for Non-Medical Professionals
Reviewing Medical Records
Why Are Pediatric Patients Different?
What Should the Child’s Chart Contain?
Red Flags in the Chart
How Do I Know if I Need a Pediatric Expert?

Chapter 33: Perioperative Records
Pre-operative Period
Pre-Surgical Phase
Intraoperative Nursing Documentation
Documentation of Anesthesia Care
Post-Anesthesia Care Unit Documentation
Outpatient Surgery Discharge

Chapter 34:Physician Documentation in Hospitals and Nursing Homes
Physician Roles and Responsibilities for Documentation
Forces That Shape Documentation
Accreditation Requirements

Chapter 35: Psychiatric Records
The Development of the Diagnostic and Statistical Manual of Mental Disorders
Use and Structure of the Diagnostic and Statistical Manual of Mental Disorders
Validity, Reliability, and Limitations
The Diagnostic Process
The Medical Record—From Diagnosis to Discharge
The Multidisciplinary Team and Documentation in the Medical Record
Psychiatric Terminology and Accuracy in Communication in the Medical Record
Uses and Misuses of Terminology
Documenting Special Circumstances in the Medical Record

Chapter 36: Rehabilitation Records
The Rehabilitation Team
Scope of Documentation

Chapter 37: Skin Trauma
Pressure Ulcers

Chapter 38: Controversies in Skin Trauma
Surgical Wounds
Psychological Factors Associated with Skin Trauma
Overview of Wounds
Pressure Ulcers
Quality of Nursing Care and Documentation in Long-Term-Care Facilities
Controversies in the Use of Specialized Care for the Prevention and Treatment of Pressure Ulcers
Nutritional Support in Wound Healing


Part Four: Forensic Aspects

Chapter 39: Tampering with Medical Records
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

Chapter 40:The Forensic Examination of Medical Records
What Is a Forensic Document Examiner and How Is One Located?
How Can a Forensic Document Examiner Assist the Attorney?
The Importance of Knowing the Charting Habits of the Medical Personnel

Chapter 41: Forensic Medical Records
Definitions of Forensic Nursing
Forensic Professionals
Location and Provision of Forensic Services
Common Forensic Issues
Trauma Quality Management (TQM) and Forensic Cases
Principles of Forensic Documentation
What Is Forensic Evidence?
Commonly Occurring Forensic Circumstances Requiring Evidence Recovery
Bite Marks
Gunshot Wounds
Forensic Toxicology
Sexual Assault
Ethical Issues and Legal Precedents

Chapter 42: Autopsy Reports
Death Investigation System Development
The Death Investigation Systems in Modern America
The Stages of Death
Pronouncing and Criteria for Reporting a Death
The Death Investigation Team
The Forensic Pathologist
Types of Autopsies
Exhumation of a Body
Key Components of the Forensic Reports
Definition: Medical-Legal



Medical Terminology, Abbreviations, Acronyms, and Symbols
Internet Resources
Textbook References


















































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