LNCtips.com: 4 Little Details
Legal nurse consulting involves attention to detail. Recognizing the significance of details in the medical records may make the difference in whether the plaintiff or defense prevails. Attention to detail is important for LNC reports as well. The way your reports are written won't decide the fate of the case. But a polished report will show the attorney that details are important to you. So here are four little details that you can use to fine-tune your reports.
1) Brand names of medications begin with a capital letter, e.g., Xanax or Oxycontin. Unless they're the first word in a sentence, type generic medications in all lower case letters, e.g., alprazolam or oxycodone. If you want to make it easy on yourself and the attorney, you can put both the brand name and the generic name in your summary or chronology. Here's an example: Dr. Anderson ordered 0.25 mg of Xanax (aprazolam) three times a day for the patient's anxiety.
If you're not sure if the medication is a brand or generic, there are plenty of medication websites such as Drugs.com and MedicineNet.com to help you. Or you can Google the medication name with the words "generic" and "brand" ( without the quotes).
2) In medical records, treaters sign their names at the END of their chart entries. When creating a medical chronology, put the treater name at the BEGINNING of the chronology entry. Why? Instead of having to scan the entire chronology entry, it's easier for the LNC and attorney to identify who wrote the particular entry when it's at the beginning.
3) When referring to a particular type of medical record (progress notes, MARs, nursing notes, interdisciplinary notes, etc.), refer to the records in your reports with the exact title of each of the records. Why? It helps the legal team find specific documentation. If the medical record has no title or is called a Nursing Note in the chronology but really is a Nursing Narrative Report, it may be more difficult to locate.
4) Type narrative reports, letters, and summaries in full justification. Why use full justification? It looks more polished and is the standard in most law firms. The default for Microsoft Word and WordPerfect is left justification (also called left alignment), meaning the left edge of the document is flush but the right edge is ragged. Look at the paragraph labeled number one on this web page for an example of left justification. Then imagine an entire document typed this way. A document that's typed in full justification has flush edges on both the right and the left. In contrast, look at the paragraphs numbered two, three and four of this webpage for examples of full justification. You can imagine that an entire document typed in full justification will look better than one that's not. However, you'll want to continue to type tables in left alignment. Full justification creates too much white space in tables.
There you have it. Four little details that can make your reports so polished they will shine.