(Private) Reading Medical Records: What Really Happened?? for York County ME Bar Associates
Medical Records can be daunting for any criminal attorney or investigator to review. The purpose of the presentation is to assist attorneys in focusing their review of medical records and to focus on review of records that contain the information that both civil and criminal attorneys are commonly seeking. To make it relevant and interesting, the records included in this presentation follow an attempted murder case and highlight not only what is in the records but also what might be missing.
Highlights
- Introduction
- Discharge Summary, H&P, Consults
- Review of records that summarize the patient’s care while in the hospital
- Distinguishing between narrative reports
- Emergency Department Reports
- Review of the types of records and where to find critical information
- Brief review of labs
- Transport Records
- How to tell the difference between Pre-hospital (911 providers) and Interfacilitytransports and levels of care provided
- What information can be critical to your case
- Surgery and Radiology
- How to read operative reports
- Where to find the information you need on XRay and CT Scan reports
- Medications and Orders
- When is a drug actually given and why orders can be confusing
Objectives
Upon completion of this course, the attendee will:
- Be able to recognize where to find pertinent case information within the medical records.
- Be able to determine when medications were administered and where to look for medication errors.
- Recognize red flags for medical errors in operative reports.
- Understand different modes of medical transport and levels of care provided.
- Identify documents and who is responsible for the information within.
- CLE credit is available
“I attended the medical records training today and it was one the most helpful trainings I’ve been to in a long time. Easy to follow and a ton of very helpful information packed into a short amount of time. I signed up for the other 3 as soon as I was done. Thank you!! I bet I’ll be reaching out for help in the future. Thank you”
– Paul
“Great information. I especially appreciated the discussion about types of medical records that can be helpful and may be out there, including language to include in the request.”
– Sara
Speakers
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Merriam Young, MS RN CCRN TCRNForensic Nurse ExpertMerriam has been a nurse for 25 years, 16 of which include care of trauma patients, and the last 9 years in Surgical ICU. The last nine years she has worked in the Surgical/Trauma Intensive Care Unit at Stanford University Medical Center. Merriam has a Bachelor of Science in Nursing from the University of Pittsburgh and a Master’s in Nursing from San Jose State University. She has a certificate in Forensic Nursing from the University of California in Riverside. She is a certified critical care nurse and a trauma certified nurse. Merriam has completed the four-day Advanced Strangulation Course and has reviewed multiple strangulation, assault, DUI, domestic violence, and homicide cases. Merriam has been qualified to testify on strangulation, blunt force trauma, traumatic brain injury and acceptable medical practice for blood draws.
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MS RN CCRN TCRN
