RMR

Medical Record Review: How not to “google” every term

Tara M Godoy, BSN RN LNC
Certified Forensic Nurse

Summary:

The records included in the presentation follow an attempted murder case and highlight not only what is in the records but also what might be missing. The purpose of the presentation is to assist attorneys in focusing their review of medical records by locating summaries within the documents, avoiding “filler,” and identifying red flags. Participants will learn how to find the information that will assist them in determining when an expert is needed.

Highlights

  1. Introduction
  2. Discharge Summary, H&P, Consults
    • Review of records that summarize the patient’s care while in the hospital
    • Distinguishing between narrative reports
  3. Emergency Department Reports
    • Review of the types of records and where to find critical information
    • Brief review of labs
  4. Transport Records
    • How to tell the difference between Pre-hospital (911 providers) and Interfacility transports and levels of care provided
    • What information can be critical to your case
  5. Surgery and Radiology
    • How to read operative reports
    • Where to find the information you need on XRay and CT Scan reports
  6. Medications and Orders
    • When is a drug actually given and why orders can be confusing