LNCtips.com: 3 Bad Habits with Medical Records

We all have bad habits.  Maybe we eat ice cream while we're watching TV.  Maybe we leave dirty dishes in the sink.  Maybe we smoke or don't exercise enough.  Legal nurse consultants can develop bad habits with medical records too.  These bad habits aren't annoying and they're not hazardous to our health.  However, these three faults can affect your time, something that always seems in short supply.

What are these bad habits? 

Reviewing medical records without knowing the case.  This is the most common error that I've seen with new legal nurse consultants.  New LNCs are so frantic to learn about their first cases that they often delve immediately into the records.  If you're one of those LNCs, ask yourself this:  Ideally, would you take care of a patient without knowing what his or her nursing needs were?  As an LNC, treat the medical records as if they were a patient.  Have a thorough conversation about case allegations with the potential plaintiff (if applicable), attorney, or attorney representative and read any supporting documents (such as a Complaint and Affidavit, if applicable) before analyzing the records.  After that, conduct medical research, if needed, so that you have a good understanding of the standards of care related to the allegations.  Only after that should you start reviewing the records.

Reviewing medical records as you organize them.  Paper medical records are much easier to read if they're organized.  However, reading them as you organize them will almost certainly result in one of two things: poorly organized records or re-reading the records after you organize them.  Either way, it's a big time-waster for you and an unnecessary expense for your employer or client.  The solution is to organize your records first, then read them thoroughly.  Or you could read the records "as is" or hire a clerk and teach him or her how to organize records so that you won't be tempted.

Reviewing medical records multiple times.  There are legitimate reasons to read records more than once.  For example, you may want to refresh your memory before you talk to an expert or a client, or you may want to do a focused medical analysis of a specific issue.  The problem I'm referring to is the LNC who reads the records once "to get a feel for them" then reads them multiple times to try to make sense of them.  There are several unique approaches to reviewing medical records, but re-reading them repeatedly isn't one of them.  If you are reading medical records again and again, you might suffer from analysis paralysis.  Use prevention techniques to get yourself back on track.

Breaking any bad habit takes effort.  However, if you break these bad habits, your effort will be rewarded with more time.  And who doesn't need more time?

...Katy Jones