Medical Record As A Forensic Resource / Edition 1

by Campion E. Quinn

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
Product dimensions:	6.00(w) x 1.25(h) x 9.00(d)

Table of Contents

	Contributors	vii
	Acknowledgments	ix
	Introduction	xi
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
31	Appendix I-Glossary of Malpractice Terms	209
32	Appendix II-Medical Abbreviations	225
33	Appendix III-Medical Chart Checklists	261
	Index	265

Editorial Reviews

3 Stars from Doody

Reviewer: Nicholas Greco IV, MS, BCETS, CATSM, FAAETS (C3 Education and Research, Inc.)
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!

Doody's Review Service