LNCtips.com: 2 Reasons For Incomplete Records
When you took your legal nurse consultant course, the instructor probably told you to review all the medical records, policies, procedures, and other materials from the healthcare provider to determine if healthcare workers breached the standards of care. There are two reasons those instructions are a problem, and that problem might just affect your review.
There are two reasons why LNCs might have to review incomplete materials:
1) The plaintiff attorney might not want to spend money to obtain a complete set of medical records. Most plaintiff attorneys foot the bill for expenses, such as the cost of copying medical records, behind-the-scenes case review, and expert case review. Unless attorneys are certain that medical malpractice has occurred, they may order abstracts, which are condensed, incomplete sets of the medical records.
2) Before a lawsuit is filed, the plaintiff has no ability to obtain policies and procedures or other internal documents of the healthcare provider. (There are some exceptions in states with pre-litigation requirements.) Those materials belong to the healthcare provider and it doesn't have to share them with anyone. Therefore, attorneys can't provide those materials for review. Once the lawsuit is filed, plaintiff attorneys can obtain many of the healthcare provider's internal documents through the Discovery process.
How should LNCs handle this situation? There are three options:
1) If there are blantant deviations from well-known standards of care, you may not need the additional records/documents until after the case is in suit. For example, if healthcare workers failed to follow national Advanced Cardiac Life Support standards, the healthcare provider's policy and procedures for cardiopulmonary rescusitation aren't urgently relevant. In any case, inform the attorney of your opinion and request the other materials when they become available.
2) If deviations aren't apparent, inform the attorney, but suggest that a complete medical chart might be helpful to validate or negate the plaintiff's allegations. The attorney will then decide to proceed with the case or not.
3) If there appear to be deviations, but the incomplete documents might sway your opinion, inform the attorney. For example, if a plaintiff is alleging that his plastic surgery caused disfigurement, you would probably need to see photographs to validate his allegation. If you have reservations because of incomplete documents but need to sign an affidavit of merit, consider adding the phrase, "I reserve the right to alter my opinon if additional materials come to my attention,"
Reviewing incomplete medical records is a reality for many legal nurse consultants who review cases for plaintiffs. If you're confronted with incomplete medical records, you can follow the strategies above to try get complete copies.
Want to learn more about medical record review by legal nurse consultants? Check out the Archives.