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Medical Record As A Forensic Resource / Edition 1
     

Medical Record As A Forensic Resource / Edition 1

by Campion E. Quinn
 

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ISBN-10: 0763727598

ISBN-13: 2900763727597

Pub. Date: 10/07/2004

Publisher: Jones & Bartlett Learning

Medical charts and records are often a critical component in the litigation of medical malpractice, personal injury, and product liability cases. And to the legal professional, the medical chart is often an intimidating document, filled with unfamiliar medical jargon and indecipherable abbreviations. In The Medical Record as a Forensic Resource, Campion Quinn, a

Overview

Medical charts and records are often a critical component in the litigation of medical malpractice, personal injury, and product liability cases. And to the legal professional, the medical chart is often an intimidating document, filled with unfamiliar medical jargon and indecipherable abbreviations. In The Medical Record as a Forensic Resource, Campion Quinn, a physician with expertise in both writing and reviewing medical records, brings together the legal world and the world of medicine. Quinn explains what a medical record is, what it should contain, how to acquire, review, and report on the content, as well as how to extract relevant information for investigations. Filled with sample clinical notes, test results, physician and nurse reports, and checklists, the book describes how a chart can be examined, ordered, categorized, and explained in the clearest, most efficient way. Quinn also addresses the admissibility of the medical chart as evidence, and how to identify tampering. The Medical Record as a Forensic Resource is an absolute must-have for both those who work in the legal field and need to develop a competency in medical chart review, and also those health care professionals without a legal background who can benefit from chapters on the basics of malpractice and personal injury litigation.

Product Details

ISBN-13:
2900763727597
Publisher:
Jones & Bartlett Learning
Publication date:
10/07/2004
Edition description:
1E
Pages:
277

Table of Contents

Contributorsvii
Acknowledgmentsix
Introductionxi
1What Is the Medical Chart?1
2Acquiring a Medical Record5
3Authorization for Release of Medical Information15
4Determining What Is Missing from a Medical Chart17
5How to Examine an Individual Medical Chart21
6Face Sheet27
7Consent Forms31
8Living Will/Power of Attorney35
9Preadmission Records41
10Ambulance Call Report45
11Emergency Department Record51
12Admission Note65
13Physician Order Sheet73
14Progress Note79
15Consultation Note85
16Anesthesia Note89
17Procedure Note95
18Discharge Summary99
19Radiology Report103
20Laboratory and Pathology Reports107
21Autopsy Report111
22Nursing Notes115
23Medical Policies123
24Incident Reports127
25Medication Errors135
26The Medical Chart as Evidence155
27Tampering or Falsification?165
28Malpractice Basics171
29Pain and Suffering181
30Personal Injury Claims195
31Appendix I-Glossary of Malpractice Terms209
32Appendix II-Medical Abbreviations225
33Appendix III-Medical Chart Checklists261
Index265

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