Medical Records Review and Analysis / Edition 1

by Charles C. Sharpe

Overview

The review and analysis of medical records is a very important part of any personal injury or malpractice case. This book provides an introduction to the law and basic principles as they apply to medical records. It provides a comprehensive list of guidelines for obtaining, reviewing, interpreting, and understanding the documents in a typical record. It offers a useful glossary, a selection of relevant websites, a review of state laws that deal with access to medical records, and an extensive list of abbreviations that may be encountered in clinical practice. While the author does not offer specific legal advice, he gives the reader all of the tools needed to research and utilize medical records. Laypersons, attorneys, paralegals, legal assistants, nursing professionals, medical practice administrators, risk managers, and law students will find this a very useful reference and guidebook.

Product Details

ISBN-13:	9780865692831
Publisher:	Bloomsbury Academic
Publication date:	05/30/1999
Pages:	224
Product dimensions:	6.14(w) x 9.21(h) x 0.56(d)

About the Author

CHARLES C. SHARPE is a retired pediatric clinical nurse specialist. In addition to his many years of experience in clinical nursing practice, the author has been a faculty member of the departments of nursing and paralegal studies in several colleges in southeastern Pennsylvania. He is also the author of Nursing Malpractice: Liability and Risk Management (Auburban House, 1999).

Table of Contents

Preface
Review of the Medical Record in Cases of Personal Injury and Malpractice
The Medical Record
The Medical Record: Ownership, Access, and Retention
Obtaining a Medical Record
Confidentiality and Privacy Issues
Contents of the Medical Record
Altered or Tampered Records
Preparing for the Review
The Review and Analysis of the Documents in a Medical Record
Expert Witnesses and Consultants
Cybercare and Medical Records
Appendixes
Glossary
Bibliography