Medical Record Review, Fundamental to the Legal Nurse Consultant RoleMedical record review is second nature to nurses. No one handles the patient medical record more often than the nurse. You can turn this skill into a profitable career as a Legal Nurse Consultant. The patient medical record involves the documentation of integrated patient care...covering multidisciplinary issues. You may be reviewing documentation in both electronic and written format. Either way, your nursing knowledge and some strong detective skills can help to prove or disprove allegations involving patient injury through negligence or malpractice. You will be responsible for interpreting the medical jargon for the attorney, patient and possibly jury. Being able to communicate in clear and understandable language to non-medical persons is an essential skill that you have practiced over and over in patient education.
Understanding the Legal Aspects An understanding of the legal aspects of patient injury cases is also essential to effective legal nurse consulting. One of the first tasks is often an initial medical record review to evaluate a potential client's claim and the extent of injuries. Is this case worth pursuing? Your assessments based on your legal nursing knowledge can be instrumental in saving an attorney from wasting a lot of time and expense in pursuing a lost cause. On the other hand, you can point out omissions, tampering of records or errors committed that will help solidify a case. As a nurse, you know what to look for and where to find the documentation. You can assist an attorney, insurance company or risk manager in legally obtaining all authenticated records. Where to Locate Patient Medical Record Because medical records legally belong to the place of origin, you may need to retrieve them from various sources. You will get clues from the patient chart as to where else to look. Consider the following possible pieces in the puzzle. Then obtain proper authorized permission from the patient:
Systematically Review and Summarize All Documents The purpose of all MR summaries is to provide a clear road map...charting the timing, extent and recovery of a client's injuries. You will not be interpreting the quality of medical care received by the patient. That will be up to an expert in the appropriate specialty. You are only objectively documenting the information as it appears in the patient chart. There are different forms for medical record review. Narrative and Chronological Summaries are the most common methods. Find out which form and method your attorney prefers. Medical record review is only part of what a Legal Nurse Consultant does. For more information check out the Legal Nurse Consultant page
Good luck in whatever venture you nursing career takes. Drop me a line if youare able to build the nursing career of your dreams. I can be reached at nursing1@nursing-career-hub.com
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