- Screen your potential malpractice and personal injury cases more effectively
- Gain the tools needed to better decipher the complexities of the medical record
- Achieve understanding into what constitutes a 'complete' medical record
- Learn who all the 'players' are and what their specific roles in documentation comprise
- The attendee will be able to discuss malpractice and personal injury cases more effectively.
- The attendee will be able to identify the styles of documentation used in the industry.
- The attendee will be able to review chart evaluations.
9:00 a.m. - 9:15 a.m.
9:15 a.m. - 10:15 a.m.
II. Components Of The Medical Chart
A. Face Sheet
B. Admitting Note
C. ER Records
D. History and Physical
E. Progress Notes
F. Medical Orders
G. Medication Administration Records
H. Nursing Care Plans
K. Flow Sheets
L. Ambulance Care Reports
III. Who Documents On The Chart?
A. M.D. (Residents, Fellows, Students, Attending)
B. R.N. (LPN, Students, Assistants)
10:15 a.m. - 10:30 a.m.
10:30 a.m. - 12:00 p.m.
IV. Documentation Styles
A. Admitting Notes vs. Progress Notes
B. SOAP Charting
C. Terminology And Accepted Abbreviations
D. Examples Of Unacceptable Abbreviations
E. Documentation Based On Age Groups
12:00 p.m. - 1:00 p.m.
Lunch (On Your Own)
1:00 p.m. - 2:45 p.m.
V. How To Evaluate A Chart
A. 'What's The Question'?
B. Compiling And Evaluating Information Based On 'The Question'
C. What's Important To You As An Attorney?
D. Red Flags: Dates/Times That Don't Follow, Addendums, Omissions, Possible Alteration Or Tampering
VI. How We Evaluate A Chart
2:45 p.m. - 3:00 p.m.
3:00 p.m. - 4:30 p.m.
VII. Putting It All Together
A. Do You See What We See?
B. Case Reviews And Discussion