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Volume 26 Number 2 Summer 2015 THE JOURNAL OF egal Nurse Consulting ELECTRONIC MEDICAL RECORDS

Organizes your existing facts so well, youll have time to find new ones. LexisNexis has two software applications designed around a legal nurse consultants workload CaseMap and MedMal Navigator, our n

THE JOURNAL OF egal Nurse Volume 26 Number 2 Summer 2015 Consulting 08 A REVIEW OF ELECTRONIC HEALTH RECORDS FOR LEGAL NURSE CONSULTANTS Bryan A. Wilbanks, DNP, CRNA Information management syst

PURPOSE American Association of Legal Nurse Consultants 330 North Wabash Ave. Suite 2000 Chicago, IL 60611 8774022562 3123215177 Fax 3126736655 Email Web site The purpose

ARTICLE SUBMISSION The Journal of Legal Nurse Consulting JLNC, a refereed publication, is the official journal of the American Association of Legal Nurse Consultants AALNC. We invite interested nurses

FROM THE PRESIDENT A Message from the President Varsha Desai BSN, RN, CNLCP, LNCC President, AALNC AALNCs top three objectives from the strategic plan include 1. Position AALNC as the industry leade

FROM THE EDITOR June 2015 Editors Note Were focusing on electronic health records EHR, and I must say, Ive learned a lot of very interesting things while weve been putting it together. One thing tha

LETTERS TO THE EDITOR online, as my lists are public and search engine indexed. I will also list these journals in my Social Work and Public Health Research Guides on the Temple University research g

3. You are welcome to send your letter anonymously if you deem this necessary. However, it would be better though if you identified yourself in the letter and, even better, offered the ONC an opportun

FEATURE A Review of Electronic Health Records for Legal Nurse Consultants Bryan A. Wilbanks, DNP, CRNA Keywords information management system, electronic medical record, electronic health record, ele

2010. Meaningful use is defined by a delineated set of objectives to be met in order for the facility to receive financial reimbursement or other incentive. Some include maintaining uptodate patient h

Information technology in clinical settings has been associated with unintended consequences, adverse events that are a direct result of implementing or using information technology. provide immediat

guide staffing decisions for the entire operating room, which could save money by allowing appropriate utilization of human resources Junger et al., 2002. Reich et al. 2006 demonstrated that an IMS r

medical record to save time writing it de novo. Copyandpaste functionality may decrease enduser workload and total documentation time, but can result in decreased documentation quality that directly e

Junger, A., Benson, M., Quinzio, L., Michel, A., Sciuk, G., Brammen, D., . . . Hempelmann, G. 2002. An Anesthesia Information Management System AIMS as a tool for controlling resource management of op

FEATURE Electronic Health Records The Promise and Reality Patricia Iyer, MSN, RN, LNCC Armand Leone, MD, JD and, Rebecca J. Zapatochny Rufo, DNSc, RN, CCRN Keywords electronic medical record, electro

documented patient care. The Health Information Technology for Economic and Clinical Health HITECH Act required that healthcare providers implement Electronic Heath Records EHR, that physicians demons

use. EHRs are not subject to regulatory oversight, and FDA approval prior to use is not required. EHRs were designed to accurately code for payment not treatment. As a general rule, less than 50 of EH

the physician of any missing data. It did not request him to specify 150 pounds vs. 70 kilograms, so it failed to alert the provider the measurement was missing. Obscured information is another design

the evidence based practice guidelines. Then the day shift nurse comes in at 700 AM and says, Oh my, this patient has pneumonia and sepsis. My guidelines arent in and I dont have all the appropriate d

errors are easy and obvious to detect, such as the 83yearold lady whose age is listed as 38, but not all. There is no FDA approval for EHRs as there is for medical devices and tests. There is no syste

FEATURE Terry K, EHRs Not Reliable for Legal Cases, Experts Say. Medscape Medical News, http www.medscape.comviewarticle832822 Oct. 3, 2014 Retrieved 332015 4 Armand Leone, Jr, MD, JD, MBA is a lice

FEATURE Audit Logs Scott Greene, CEO, Evidence Solutions, Inc. Keywords EHR, EMR, chart audit, audit logs, audit trail, data breach, health records Audit logs and metadata are key to proving when ch

Medical billing Ensuring accurate billing, including the proper charge for services or procedures. Medical bills were computerized long before medical records were. But with integration, comes automat

WHAT IS THE USE OF AN AUDIT LOG IN LITIGATION Audit logs can help bolster either plaintiff or defense claims about whether procedures were performed at the times that the clinician states they were pe

health care industry needs to defend against sophisticated cybercriminals who seek critical medical data to commit fraud or turn a profit. HACKS AND DATA BREACHES DONT COME JUST FROM THE OUTSIDE Kayn

FEATURE Follow the Audit Trail May 2014 Jennifer Keel Reprinted with permission of Trial May 2014, Copyright American Association for Justice, formerly Association of Trial Lawyers of America ATLA

The use of EMRs has been on the rise since 2004, when President George W. Bush launched an initiative to computerize health records.1 This progression advanced exponentially when the Centers for Medic

raneously at the terminal in your clients room was telling the truth, focus the audit request on that nurse without limiting it to your client. In that instance, you might ask for the audit records th

DEPOSITIONS Once you have the documents, you may find that the complexion of your case changes. If you have witnesses who have already been deposed, go back and compare their answers to the evidence i

FEATURE Documented But Not Done Katy Jones, MSN, RN, LNC Reprinted with permission from, 2015 s nurses, weve all learned the phrase Not documented, not done. The phrase implies that if

How will plaintiffs prove that the care wasnt done Theyll do it the same way that defendants prove that they actually performed care that wasnt documented by verbal testimony. Independent and inhouse

FEATURE Roundtable Discussion on Electronic Health Records Curated by Cheryl Gatti, BSN, RN, LNCC, CCRNR L NCs are reviewing more Electronic Health Records EHRs. To create a dialogue regarding issu

FEATURE I often see many pages of data that are detached from each other. For example, dozens of pages of systolic BPs, followed some inches later by the corresponding diastolics, and maybe later by p

PHI under HIPAA, which is a good idea anyway for other reasons, but this makes it even more important. JLNC What do you think about CPF the copyand paste feature The Joint Commission has received repo

YES Had a 6 week old where the EHR documented nonsuicidal, nonhomicidal. The MD had a hard time answering that question in deposition. Yes, in an ortho case. All of the times that the tourniquet was a

passwordprotected login minimize fraud and prevent tampering. It can facilitate good clinical practice, as long as management takes advantage of things like bedside documentation and chart auditing. O

Ask counsel to request the records by section and then by date all MAR together, all MD orders together, all operative records together, etc. This is HUGE JLNC Do you have toolstips you have found he

THE JOURNAL OF egal Nurse Consulting Looking Ahead... XXVI.3, September 2015 Expert Witnesses XXVI.4, December 2015 ACA and LNC XXVII.1, March 2016 Research in LNC XXVII.2, June 2016 LNC Writte