The Medical Record as a Forensic Resource

Softcover, 277 pages
ISBN 0763727598
9780763727598
Jones & Bartlett
Copyright 2005
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The Medical Record as a Forensic Resource describes what a medical record is, what it should contain and how to acquire, review, and report on its content.

This book contains valuable information on the basics of malpractice and personal injury litigation as well as how the medical chart review can be integral to the proper adjudication of a case. The Medical Record as a Forensic Resource is an absolute must-have for both those who work in the legal field and need to develop a competency in medical chart review, and also those health care professionals without a legal background who can benefit from chapters on the basics of malpractice and personal injury litigation.

This book is full of sample clinical notes, test results, physician and nurse reports, and checklists to assure completeness. Topics fully covered include:

Acquiring the Medical Chart
Release of Medical Records
Determining What is Missing From the Medical Chart
How to Examine the Medical Chart
- Fact Sheets
- Consent Forms
- Living Wills
- Pre-admission Records
- Ambulance Call Reports
- Emergency Department Records
- Admission Notes
- Physician Orders
- Progress Notes
- Consultant’s Notes
- Anesthesia Notes
- Procedure Notes
- Discharge Summary
- Radiology Reports
- Laboratory Reports
- Autopsy Reports
- Nursing Notes
Medical Policies
Incident Reports
Medication Errors
The Medical Chart as Evidence
Tampering with the Medical Records
Malpractice Issues
- Pain and Suffering
- Personal Injury Cases
Medico-legal Terminology
Medical Abbreviations
Medical Chart Check Lists
- Physician Office Chart
- Hospital Chart
- Clinic Chart
- Missing Items Checklist

Campion Quinn, MD, FACP, MHA has worked as an internist, emergency department physician and geriatrician and is board certified in all three specialties. He has served as a chief medical officer to several regional and national managed care companies. Dr. Quinn has published many articles on medical diagnosis, clinical care, legal and medical management topics as well as several books on Case Management. He continues to review medical charts for lawyers and insurance companies as well as acting as an expert witness in medical malpractice and personal injury cases.

(information from the publisher)

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