Reading Medical Records: What You Need to Know Without “Googling” Every Term (On-Demand)

Course Description

Medical Records can be daunting for any criminal attorney or investigator to review. The purpose of the presentation is to assist attorneys in focusing their review of medical records and to focus on review of records that contain the information that both civil and criminal attorneys are commonly seeking. To make it relevant and interesting, the records included in this presentation follow an attempted murder case and highlight not only what is in the records but also what might be missing.

Principles

• Be able to recognize where to find pertinent case information within the medical records.
• Be able to determine when medications were administered and where to look for medication errors.
• Recognize red flags for medical errors in operative reports.
• Understand different modes of medical transport and levels of care provided.
• Identify documents and who is responsible for the information within.

Syllabus

1. Introduction
2. Discharge Summary, H&P, Consults
   • Review of records that summarize the patient’s care while in the hospital
   • Distinguishing between narrative reports
3. Emergency Department Reports
   • Review of the types of records and where to find critical information
   • Brief review of labs
4. Transport Records
   • How to tell the difference between Pre-hospital (911 providers) and Interfacility transports and levels of care provided
   • What information can be critical to your case
5. Surgery and Radiology
   • How to read operative reports
   • Where to find the information you need on Xray and CT Scan reports
6. Medications and Orders
   • When is a drug actually given and why orders can be confusing

Instructor

Tara Godoy, BSN RN CFN