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Hot Tips for Medical Record Review
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1. Chronologically organize a COMPLETE set of medical records (MUST be complete). May be an advantage to first chronologically organize records by subgroups, i.e. authors, review and then blend ALL records by date.
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2. If screening for merit, identify the elements that need to be proved.
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3. Identify the PERTINENT Records for the theme.
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4. Determine if the prior medical-surgical records bear a relationship to the pertinent records. (Pre-existing problems can cause or contribute to an injury or damages.)
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5. Assess if there is a need to review school/scholastic and employment records. (May be pertinent to the outcome and/or damages.)
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6. Summarize ALL pertinent medical records as related to the case theme. (date, author, findings, diagnosis/es, treatment)
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7. Request the original or first copy of any illegible record.
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8. If the medical record summary proves suspect to the outcome, or is not consistent to the damages, request to review the original records at the place/facility of record. (Look at the BIG picture!)
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9. If tampering is suspected, consult with a Certified Legal Nurse Consultant or a Forensic Document Examiner.
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10. Think of the medical records as a WITNESS!
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