6 Ways to Find Chart Information



LNCtips.com: 6 Ways to Find Chart Information

When I'm with an attorney who's trying to find information in the medical records, the attorney usually looks through the chart for only a nanosecond, then hands it to me and says, "Here, YOU find it." When I first started as a legal nurse consultant, I spent a lot of time shuffling through records trying to locate specific information.  It was an unsettling feeling as attorneys watched me page frantically through the chart.  Now, it takes me just another nanosecond.  Here are six ways that I've learned to locate information in medical records quickly and easily.

1. Make a copy of the pages that are important to the case.  On the copy, write the name of the provider of the medical records, and indicate how they were obtained.  For example, write "Cedar Ridge Hospital RFC Smith," for records that you received from defendant Smith from a request for copies.  This method lets you use the copy to quickly find the location of the records.  In this case, you would look in the file entitled Cedar Ridge Hospital from RFC Smith.  This method of locating important records is particularly helpful if you don't consolidate records into a working copy

2) Flag important records.  I think most LNCs and attorneys use this method, but let's take it a step further.  For example, if you know that the attorney will want to discuss key medical record entries, put a colored flag on those documents.  I like to use different colored flags for different defendants or potential defendants.  For example, I might flag key entries by treating physicians in red, by the nursing staff in blue, etc.  This method of locating important information works great with working copies.

3. Note the location of the information in a report.  I learned this trick very early in my LNC career when an attorney asked me to show him a report from a physician.  I had mentioned the report in a medical summary for the attorney.  However, I couldn't find the report.  I had reviewed a lot of medical records, but none from that particular physician. After a big delay, I eventually located the information in a chart from an outpatient surgery center. Now, if a situation like that happens, I note the location of the information in my report.  For example, I might write, "The pathology report from ABC Labs (found in the records of Dr. Trenton) showed adenocarcinoma."

4. Bates stamp the records. If you want to locate specific records, Bates stamping is a time-proven way to locate information because each page is uniquely numbered. Numbered records are particularly helpful when discussing information among members of the legal team and experts.  For example, an expert might say to an attorney, "If you look at page 00175..." Locating page 00175 is easy because all pages have a unique number. The problem with Bates stamped records occurs when you don't remember the exact numbers of chart entries. For that reason, I always add the numbers to my reports.  Here's an example: "On October 21, 2013, John Milford, MD ordered Coumadin 2.5mg (00175) based on the patient's INR of 1.9 that day (00850). However, at 4:00 p.m. that same day, Mary Langdon, RN charted that she administered 5mg of Coumadin (00998)." This method makes it a snap to find each chart entry.

5. Electronically link to the records.  All of the above ways to locate information work for physical pieces of paper.  But what if you only have the medical records in electronic format?  If that's the case, you can easily find information by linking electronically to documents.  CaseMap has a feature for linking to individual pages in any document.  If you don't have CaseMap, you can create links to your reports in Microsoft Word.  Since electronic records are becoming the norm, hyperlinking to information helps you find specific pages from medical records quickly.  Just click on a link and you're looking at the record that you need.

6. Bookmark the records.  Another way to locate information easily in electronic medical records is to bookmark important pages.  Bookmarking is the electronic equivalent of flagging paper records.  Clicking on a bookmark in the patient's electronic chart takes you directly to the page you're looking for.  You can learn how to bookmark electronic records with this tutorial.

Now if an attorney asks you to locate information in the medical records, you'll be able to instantly produce the information!

...Katy Jones