Medical Records Review and Analysis

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.

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