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Volume 29 Number 2 Summer 2018 THE JOURNAL OF egal Nurse Consulting EHR REVISITED

B THE JOURNAL OF LEGAL NURSE CONSULTING

THE JOURNAL OF egal Nurse Volume 29 Number 2 Summer 2018 Consulting 09 EHR A MEDMAL MINEFIELD FOR PRACTITIONERS Joanne Walker BSEd, RN 32 DEFENDING THE ELECTRONIC MEDICAL RECORD CHALLENGES AN

PURPOSE American Association of Legal Nurse Consultants 330 North Wabash Ave. Suite 2000 Chicago, IL 60611 8774022562 3123215177 Fax 3126736655 Email infoaalnc.org Web site www.aalnc.org 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 Presidents Update I Kim Beladi, BSN RN LNCC President, AALNC hope everyone returning from the forum arrived home to see tulips blooming and sunshine sprinkling down. I love sprin

FROM THE EDITOR Editors Note EHR Revisited Welcome to the June 2018 JLNC, a reprise of the issue on EHR from June 2015. We felt it was time to take a second look at this topic three years later, to s

FROM THE EDITOR Weve learned that automation does not eliminate errors. Rather, it changes the nature of the errors that are made, and it makes possible new kinds of errors. The bottom line is this S

LETTERS TO THE EDITOR PEER REVIEW MATERIALS CONFIDENTIAL Since the Journal of Legal Nurse Consulting is a peerreviewed publication, I found noteworthy the news that Kentucky Governor Matt Bevin had s

SCREENING SKILLS Test Your Case Screening Skills CASE 16 Molly was an RN and due to repetitive lifting of patients she developed impingement syndrome of both shoulders. Her right shoulder never felt

FEATURE Il iuntiberum aborem sequae nisi officit iatiant et rerati doluptate consequid ma ad mosa voluptat est ped ut qui blamus evelese optur aut arum simpostion porit laborrum eos exped que quiatqu

FEATURE Understanding how using EHRs may help protect them from liability, and how misuse or nonuse may increase liability risk, should motivate them to do so. misinterpretation of dropdown menus, w

a doctors order, all of which violated decades old and exceedingly clear national standards of care applicable to all U.S. hospitals.2 The MarchApril 2015 RSNA RadioGraphics contained this caveat Erro

FEATURE States involved a patient whose doctor failed to diagnose his prostate cancer in time for it to be cured. The court held that under Vermont law, the physician violated the standard of care by

The LNC who has the onerous task of organizing and reviewing these records must become familiar with the possibility of transcription errors affecting patient safety and the outcome of litigation. CO

FEATURE The Intersection Between Medicine and Law Legal Nurse Consultants Roles and Responsibilities under HIPAA Linn F. Freedman, Esq. and Kathryn M. Rattigan, Esq. INTRODUCTION The legal world and

THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 With access to medical records and medical history information from legal professionals, legal nurse consultants straddle the line betwe

FEATURE under HIPAA. Therefore, if a legal nurse consultant is an employee of a legal professional or law firm, she is required to adhere to HIPAA and the business associate agreement entered into bet

The bottom line is that legal nurse consultants are usually subject to HIPAA and state laws applicable to the access, use and disclosure of health information, as well as contractual provisions set fo

FEATURE EMRs and Litigation Issues Decided and Whats Next Matthew P. Keris, The Legal Intelligencer httpwww.thelegalintelligencer.comid1202754544467EMRsandLitigationIssuesDecidedandWhatsNextslreturn2

Although Rule 202.1 permitted the discovery of medical records presuit, it did not allow depositions or production of computerized data in native form. Applying strict construction of the precomplaint

FEATURE The EHR Files The Truth is Out There Michael Seaver RN ust as every word in an English dictionary comprises various combinations of the same 26 letters, discrete data elements make up the com

detailed audit or history will reveal the metadata, or data about the data Who entered or viewed it What was entered or viewed and if it was ever modified or deleted When the temperature was report

FEATURE Similarly, systems may establish security for specific elements of a medical record. Users may need to have specific permission to view records related to behavioral health issues or encounter

With the everincreasing number of cases that rely on the accuracy and completeness of the data within the electronic health record, the importance of locating and retaining a healthcare IT expert has

FEATURE Audit Logs Scott Greene Keywords EHR, electronic medical records, audit logs Audit logs and metadata are key to proving when changes were made in a patients electronic chart. This is a brief

AUDIT LOGS ANYONE Besides the meaningful use audit log requirements CMS, 2014, the HIPAA Security Rule and the HITECH Act OCR, n.d. and the Joint Commission each put forth specific requirements pertai

FEATURE An Application, Module, SubSystem field generally holds information about which module or subsystem of the EMR system the caregiver is using. These fields can contain entries such as Microbiol

Figure 1. the patient and told her she needed to see a specialist and gave the patient the names of two specialists. However, the data told a different story. The system allowed for phone encounters

FEATURE Navigating the Electronic Medical Record Audit Trail Lesley E. Niebel, JD ith the rise and implementation of electronic medical records EMR, new challenges have emerged in the legal field reg

DISCOVERABILITY Federal and many state laws mandate that covered entities have hardware, software, and procedural mechanisms in place to maintain audit trails for electronically protected health infor

FEATURE When requesting an audit trail, be specific in your request. This will not only prevent you from getting useless information, but will also make it more difficult for the opposing party to ob

Based on the circumstances of a particular case, it may also be pertinent to request audit trails for specific providers. If an issue arises from around the care given by a specific provider, consider

FEATURE On the following pages, a defense attorney and LNC offer their complementary perspectives on defending electronic medical record cases. 32 THE JOURNAL OF LEGAL NURSE CONSULTING

Defending the Electronic Medical Record Challenges and Approaches Edward Clausen JD Defending the Electronic Medical Record The LNC Perspective Deborah S. Susie White, RN, LNCC Electronic medical rec

FEATURE Once counsel formally tenders a request for production of documents, opposing counsel may object for many reasons they may be privileged, meaning they are protected from disclosure, or contai

Problems arise because the information displayed on the EHR computer screens inside facilities is impossible to recreate when produced in paper format. This can lead to claims that the healthcare prov

FEATURE The most important thing for practitioners to know about metadata is what metadata is available on each system. This can only be ascertained by working with your clients to determine what data

Know these limitations at the outset of litigation so spoliation arguments do not arise later. Spoliation is the intentional or negligent destruction of evidence and can create serious problems for a

FEATURE Relevance and proportionality are key to electronic discovery. The court noted that the medical record was relevant because negligence by doctors was alleged, and that the onsite inspection w

CONCLUSION Healthcare providers, some still struggling with the transition from a paper chart to the EHR, are now transitioning to new systems. Often they do not appreciate that the good faith product

FEATURE Round Table How LNCs Work With Electronic Health Records EHR Patricia Ann Stormy Green, BSHS, RN, RNFA, LNC Keywords EHR, electronic medical records, legal nurse consulting, LNC We polled pra

not allow for this, the LNC may need to create a skeleton chronology or timeline not for submission. Question 2 The attorney thinks there may be a case in the 12,000 pages of records the paralegal jus

FEATURE attorney to have a staffer locate and forward them. Suggest the attorney access an outside medical record service such as www.voxmedicus.net to organize the records. This can provide a signif

end of the spectrum Some LNCs love paper records and others hate them. LNCs who love paper records prefer them in a printed EHR format because it is easy to flip through them, especially when the EHR

Save theForum 2019 Date AALNC Annual Omni Louisville Hotel Louisville, KY Friday, April 5 Saturday, April 6, 2019 PreForum Thursday, April 4 Ad Page

THE JOURNAL OF egal Nurse Consulting Looking Ahead... XXIV.3, September Interventional Radiology XXVIII.2, June 20172018 Trials, Jury Prep XXIV.4, December 2018 Social Media XXVIII.3, September

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