Medical Records Review and Analysis / Edition 1

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Overview

The review and analysis of medical records is a very important part of any personal injury or malpractice case. This book provides an introduction to the law and basic principles as they apply to medical records. It provides a comprehensive list of guidelines for obtaining, reviewing, interpreting, and understanding the documents in a typical record. It offers a useful glossary, a selection of relevant websites, a review of state laws that deal with access to medical records, and an extensive list of abbreviations that may be encountered in clinical practice. While the author does not offer specific legal advice, he gives the reader all of the tools needed to research and utilize medical records. Laypersons, attorneys, paralegals, legal assistants, nursing professionals, medical practice administrators, risk managers, and law students will find this a very useful reference and guidebook.

An introduction and reference to the basic legal principles of obtaining, reviewing, interpreting, and understanding the documents in a typical medical record.

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Product Details

  • ISBN-13: 9780865692831
  • Publisher: Greenwood Publishing Group, Incorporated
  • Publication date: 5/30/1999
  • Edition number: 1
  • Pages: 224
  • Product dimensions: 6.42 (w) x 9.63 (h) x 0.92 (d)

Meet the Author

CHARLES C. SHARPE is a retired pediatric clinical nurse specialist.

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Table of Contents

Preface
1 Review of the Medical Record in Cases of Personal Injury and Malpractice 1
2 Legal Implications of Informed Consent and Advance Directives 13
3 The Medical Record 25
4 The Medical Record: Ownership, Access, and Retention 35
5 Obtaining a Medical Record 45
6 Confidentiality and Privacy Issues 53
7 Contents of the Medical Record 67
8 Altered or Tampered Records 73
9 Preparing for the Review 81
10 The Review and Analysis of the Documents in a Medical Record 89
11 The Summary Report 129
12 Expert Witnesses and Consultants 135
13 Cybercare and Medical Records 151
App. I Web Sites 161
App. II State Laws on Patient Access to Medical Records 165
App. III List of Documents in a Medical Record 168
App. IV Abbreviations Commonly Used in Medical and Nursing Clinical Practice 172
Glossary 189
Bibliography 199
Index 203
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