The Medical Record As A Forensic Resource / Edition 1

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Overview

The Medical Record as a Forensic Resource describes what a medical record is, what it should contain and how to acquire, review, and report on its content. It contains valuable information on the basics of malpractice and personal injury litigation as well as how the medical chart review can be integral to the proper adjudication of a case. A must for anyone working in the legal field, this book will also educate readers without a legal background on the basics of malpractice and personal injury.
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Editorial Reviews

Doody's Review Service
Reviewer: Nicholas Greco IV, MS, BCETS, CATSM (Columbia College of Missouri)
Description: This book is successful at helping to close the gap between medicine and law in terms of understanding and interpreting the medical record. Quite often, the medical record is seen as a maze of information, jargon, and illegible writings. The author helps provide readers with the foundation to navigate this often confusing world.
Purpose: The purpose is to provide knowledge and understanding about how a medical chart is created, what it says, what it doesn't say, what it means, and what it should say. The book is written for lay persons to understand the medical and legal jargon. These worthy objectives are successfully met.
Audience: Both legal and medical professionals would benefit from this book. Those with a legal background will get the necessary medical chart review understanding, and those with a medical background will better understand malpractice, personal injury litigation, and the do's and don'ts of medical charting. The author, an MD with extensive knowledge in chart review, shares this expertise.
Features: The book is a quick reference on such topics as consent forms, living will/power of attorney, emergency room records, admission notes, progress notes, etc. The author presents a section-by-section discussion of all parts of a medical chart and supplements with examples, explanations, checklists, and a terrific question and answer format. The glossary of malpractice terms, medical abbreviations, and medical chart checklists in the appendixes are extremely useful.
Assessment: What a fabulous addition to both the medical and the legal fields. Readers will be fortunate to come upon such a detailed and highly useful resource. Definitely recommended reading for all those in medicine and in law. Make room on your shelf for this one!
From The Critics
Reviewer: Nicholas Greco IV, MS, BCETS, CATSM(Abbott Laboratories)
Description: This book is successful at helping to close the gap between medicine and law in terms of understanding and interpreting the medical record. Quite often, the medical record is seen as a maze of information, jargon, and illegible writings. The author helps provide readers with the foundation to navigate this often confusing world.
Purpose: The purpose is to provide knowledge and understanding about how a medical chart is created, what it says, what it doesn't say, what it means, and what it should say. The book is written for lay persons to understand the medical and legal jargon. These worthy objectives are successfully met.
Audience: Both legal and medical professionals would benefit from this book. Those with a legal background will get the necessary medical chart review understanding, and those with a medical background will better understand malpractice, personal injury litigation, and the do's and don'ts of medical charting. The author, an MD with extensive knowledge in chart review, shares this expertise.
Features: The book is a quick reference on such topics as consent forms, living will/power of attorney, emergency room records, admission notes, progress notes, etc. The author presents a section-by-section discussion of all parts of a medical chart and supplements with examples, explanations, checklists, and a terrific question and answer format. The glossary of malpractice terms, medical abbreviations, and medical chart checklists in the appendixes are extremely useful.
Assessment: What a fabulous addition to both the medical and the legal fields. Readers will be fortunate to come upon such a detailed and highly useful resource. Definitely recommended reading for all those in medicine and in law. Make room on your shelf for this one!

3 Stars from Doody
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Product Details

  • ISBN-13: 9780763727598
  • Publisher: Jones & Bartlett Learning
  • Publication date: 10/7/2004
  • Edition description: 1E
  • Edition number: 1
  • Pages: 277
  • Product dimensions: 6.06 (w) x 9.00 (h) x 0.58 (d)

Table of Contents

1 What is the medical chart? 1
2 Acquiring a medical record 5
3 Authorization for release of medical information 15
4 Determining what is missing from a medical chart 17
5 How to examine an individual medical chart 21
6 Face sheet 27
7 Consent forms 31
8 Living will/power of attorney 35
9 Preadmission records 41
10 Ambulance call report 45
11 Emergency department record 51
12 Admission note 65
13 Physician order sheet 73
14 Progress note 79
15 Consultation note 85
16 Anesthesia note 89
17 Procedure note 95
18 Discharge summary 99
19 Radiology report 103
20 Laboratory and pathology reports 107
21 Autopsy report 111
22 Nursing notes 115
23 Medical policies 123
24 Incident reports 127
25 Medication errors 135
26 The medical chart as evidence 155
27 Tampering or falsification? 165
28 Malpractice basics 171
29 Pain and suffering 181
30 Personal injury claims 195
App. I Glossary of malpractice terms 209
App. II Medical abbreviations 225
App. III Medical chart checklists 261
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