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Requesting Medical Records: Do you have a “complete medical record”?

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 […]


Audit Trail Analysis: Clinical Forensic Documentation Analysis

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 […]


Nursing Home RUG

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 […]


Fraudulently Copying And Pasting in the Electronic Medical Record

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 […]