An attorney’s definition and expectation of a “complete medical record” can often be as elusive as the Loch Ness Monster. In my work as a Clinical Forensic Documentation Analyst, I read countless requests for production that ask for the “complete medical record” with a laundry list of items that should be included or simply just…
Are you requesting audit logs for time clock punches? In this age of apps and remote accesses; you should be. Have you ever asked if the employer uses geofencing? Have you ever asked if the employer uses GPS tracking for employee management? If not, you could be missing critical pieces of evidence. In some medical…
You can find out a lot about a medical case through an audit trail analysis. Medical Record Tampering can be the nail in the defense coffin. In medical negligence and nursing home abuse cases, a high index of suspicion is needed when analyzing any medical record, especially the Electronic Medical Record. The medical record must…
Make no mistake, the provision of healthcare services is a business. Unfortunately, our most vulnerable citizens suffer due to corporate attempts to increase their “bottom line.” Nursing homes are regulated by the government. They must provide reports, called MDS reports, to the Centers for Medicare and Medicaid Services detailing the level of care provided to…
Many electronic medical records have the ability to copy and paste data, assessments, and multiple types of information. This feature was designed to allow for more efficient documentation. However, this feature has created many issues. The “copier”, by the very act of copying and pasting has taken the previous documentation as his own. If he…