Missing and Altered Medical Records: The Value of a Clinical Eye on Deficiencies in Medical Records (Part 1 of 4)

​All Legal Nurse Consultants (LNCs) started out first and foremost as bedside nurses taking care of patients. Nurses attend to patients' physical and emotional health needs and are responsible for documenting their care in the medical record. Most have worked in more than one hospital or office setting and have experience with more than one Electronic Medical Record (EMR). Most importantly they have inside knowledge not only on what the documentation in the medical record means, but on what should have been documented in different patient care situations.

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 Have you ever found yourself looking at a medical record and had a gut feeling or a little voice nagging, “There’s got to be something here that I’m missing”? It’s altogether possible that there is; but how do you even know what to ask for in Discovery if you’re not sure what it is that is missing? That’s where the LNC comes in.
         Nurses have background knowledge of-

• How frequently vital signs should be checked on different types of hospital wards based on acuity
• Which procedures (including “Code Blue”/Resuscitations) have additional flowsheets that may not have been a part of the electronic medical records
• Which seemingly routine procedures (such as blood transfusions, applying a splint to a broken arm) may require additional consent forms which may not be present in the electronic medical record
• Which patient care situations include incident reports that are kept internally and not considered a part of the patient’s medical record at all. This may include things such as how a patient fall or needle stick injury was handled.

Nurses also know how to get a hold of the information that is missing when traditional inquiries fail. Nurses are consistently listed among the most trusted professionals in the workforce and many hospitals and medical offices are much more willing to speak with a Registered Nurse than a legal office. Call us today for a free initial consultation to see how Pettigrew Legal Nurse Consulting Services can help you make sense of the medical records piling up on your desk- or more likely, in your DropBox. For Part Two in this series, which address some potentially valid reasons that part of your client's record is incomplete, click here.

Interested in learning more? Pettigrew Legal Nurse Consulting Services is proud to announce our approval for one CLE hour by the Georgia Commission on Continuing Lawyer Competency of our course: Missing and Altered Medical Records: Developing a Clinical Eye for Deficiencies in Medical Records. Reach out today to schedule your Lunch and Learn (in-person sessions available at your office within one hour of Canton, GA. Virtual Lunch and Learns can also be arranged. Click here to contact us.

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