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Doody's Review ServiceReviewer: 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!