(Private)Reading Medical Records: What you need to know without “Googling” every term for Montana State PDO
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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BSN RN CFN CNDI
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Tara GodoyBSN RN CFNTara Godoy is a Certified Forensic Nurse and has been working with Criminal and Civil Attorneys for over 10 years. She has a BS in Nursing from the University of Southern California and currently lives in the San Francisco Bay Area. Through consulting and testimony she has assisted both the prosecution and the defense in obtaining an honest and fair resolution in hundreds of criminal cases. Along with her nursing staff and physician contractors, Godoy Medical Forensics has consulted on over 1500 cases nationwide and has worked at both the federal and state levels. Tara has been asked to present for national organizations such as the NACDL and the NDIA at their Forensics conferences in Las Vegas. Tara’s main areas of expertise are Strangulation and Blunt Force Trauma, but testimony is also offered on other cases where traumatic injuries occur or medical record analysis is needed.
