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Medical Legal Aspects Medical Records CD - Lawyers & Judges Publishing Company, Inc.

Medical Legal Aspects Medical Records CD

$ 99.00

This product is a CD-ROM containing PDF documents. Use this book to get a comprehensive overview of the medical records process. In any health care situation, records are made, and each situation presents its own unique aspects and challenges. This book covers most medical and hospital areas of specialty, and also includes chapters on dentistry, chiropractic care, nursing homes, medications and home care. It also covers forensic issues in medical records, including examination of records and medical records obtained as part of forensic examination or autopsies.

Recent changes in legislation and technology have also changed the medical records process. The authors have designed this work to give extensive information on the HIPPA policies, standards initiatives, legal use of records, billing and coding, and computerization of records and record keeping systems and how they apply in forensic situations.This book is exceptionally valuable to all those in the legal profession or in law enforcement who deal with medical records on a regular basis.

  • Generation and preservation of medical records
  • Legal aspects of charting
  • Creation and maintenance of records in the nursing process
  • Charting systems
  • Computerized records
  • Billing and coding
  • HIPPA regulations
  • Standards Initiatives in medical records
  • Obtaining, organizing and analyzing records
  • Inpatient and outpatient specialty areas
  • Tampering with medical records
  • Forensic and autopsy records
  • Forensic examination of medical records
  • Attorney use of medical records

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Beth C. Diehl-Svrjcek MS RN, CCRN NNP CCM LNCC
Journal of Legal Nurse Consulting

(Text exerpted from review.) This review applies to the hard copy of the textbook. Upon turning the initial pages of this textbook, one becomes acutely aware that this publication is an incredible compilation of information essential to the practice of any legal nurse consultant (LNC). Penned by authors well-known for their extensive involvement and long term commitment to legal nurse consulting, Patricia Iyer, Barbara Levin, and Mary Ann Shea, the book had exceptional depth and breadth. It provides a structural foundation for medial legal record review and analysis that encompasses regulatory issues and multiple clinical specialty areas. In addition the reader is privy to the shared knowledge and clinical expertise of 50 contributing authors. These authors represent various disciplines: nursing, law, emergency medicine technology, medicine, pharmacy, chiropractic, dentistry, forensic document examination, and epidemiology. Given the vast array of contributors, the reader may surmise that the flow of the text could be somewhat erratic; however this is not the case. The authors have clearly provided a uniform concept and context upon which the book is written. This text is architecturally sound, with an outlay of information that proceeds in a methodical fashion from fundamental principles of medical record structure/format to a subsequent detailed discussion of clinical specialty areas and forensics. Given that the medical record is the keystone for clinical practice, one cannot underestimate the importance of being thoroughly familiar with how to best interpret, analyze, scrutinize, and reference all of the crucial information contained within such a document. This formidable task is simplified by referencing "Medical Legal Aspects of Medical Records". The book is divided into four major parts that independently cover the essentials of all medical legal aspects of documentation. The four parts are: Part I: Overview; Part II: Outpatient Specialty Areas; Part III: Specialty Areas; Part IV: Forensic Aspects. Interestingly, each chapter leads off with a detailed synopsis referencing specific points of discussion so that the reader can quickly seek the desired information. Throughout the text, tables, illustrations, photographs, and graphic templates of documents serve as practical examples. The frequent "Tips" on virtually every page are refreshing and effective anecdotes to highlight salient pieces for information. Chapter "Endnotes" provide the reader with an alternate listing of resources, if further exploration is needed. (review truncated here) The book concludes with an appendix of medical terminology, Internet resources, textbook references, and a glossary. These four subcomponents, as evaluated separately from the main text are excellent as a stand-alone reference for the practicing legal nurse consultant. In summary, authors Iyer, Levin and Shea have provided the legal and nursing community a comprehensive and worthwhile resource for medical record examination. Whatever your level of competence in legal nurse consulting practice, whether novice or seasoned expert, this publication will be a valuable addition to your reference library.

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