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The review and analysis of medical records is a very important part of any personal injury or malpractice case. This book provides an introduction to the law and basic principles as they apply to medical records. It provides a comprehensive list of guidelines for obtaining, reviewing, interpreting, and understanding the documents in a typical record. It offers a useful glossary, a selection of relevant websites, a review of state laws that deal with access to medical records, and an extensive list of abbreviations that may be encountered in clinical practice. While the author does not offer specific legal advice, he gives the reader all of the tools needed to research and utilize medical records. Laypersons, attorneys, paralegals, legal assistants, nursing professionals, medical practice administrators, risk managers, and law students will find this a very useful reference and guidebook.
Sommario
Preface
Review of the Medical Record in Cases of Personal Injury and Malpractice
The Medical Record
The Medical Record: Ownership, Access, and Retention
Obtaining a Medical Record
Confidentiality and Privacy Issues
Contents of the Medical Record
Altered or Tampered Records
Preparing for the Review
The Review and Analysis of the Documents in a Medical Record
Expert Witnesses and Consultants
Cybercare and Medical Records
Appendixes
Glossary
Bibliography
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CHARLES C. SHARPE is a clinical nurse specialist who has been a member of the faculty of several nursing departments in colleges in southeastern Pennsylvania./e He is also a consultant who provides litigation support and research services for trial attorneys. Presently, he is an adjunct faculty member at the Lehigh-Carbon Community College and lecturer in the Paralegal and Continuing Education Programs.
