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: ABC-CLIO, Incorporated
  • Publication date: 5/30/1999
  • Edition number: 1
  • Pages: 224
  • Product dimensions: 6.14 (w) x 9.21 (h) x 0.56 (d)

Meet the Author

CHARLES C. SHARPE is a retired pediatric clinical nurse specialist. In addition to his many years of experience in clinical nursing practice, the author has been a faculty member of the departments of nursing and paralegal studies in several colleges in southeastern Pennsylvania. He is also the author of Nursing Malpractice: Liability and Risk Management (Auburn House, 1999).

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Table of Contents

Preface

Review of the Medical Record in Cases of Personal Injury and Malpractice

The Medical Record

The Medical Record: Ownership, Access, and Retention

Obtaining a Medical Record

Confidentiality and Privacy Issues

Contents of the Medical Record

Altered or Tampered Records

Preparing for the Review

The Review and Analysis of the Documents in a Medical Record

Expert Witnesses and Consultants

Cybercare and Medical Records

Appendixes

Glossary

Bibliography

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