What Does A Legal Nurse Consultant Look For When Reviewing A Chart?
When reviewing a medical record for a legal case, a Legal Nurse Consultant will look for certain expected information, as well as missing information. For example:
Does the record contain information about the medical allegation? Records including: Emergency Room records, Emergency Dept Physician Admission History, Emergency Dept Nursing Admission History, Emergency Dept and Admission Laboratory, Radiology (Xray, CT, MRI) records, Consulting Physician records, etc.
Does the treatment information in the record meet the Medical or Nursing Standards of Care? Using resources for Medical and Nursing Standards of Care, as well as clinical experience and expertise, a Legal Nurse Consultant can analyze if the care given reflects the current standard of care for the allegation, or research the standards of care for a past time period if the allegation was historical. For example: if a patient is admitted to an Emergency Room with a trauma/motor vehicle injury, the standards reviewed would be through the American College of Emergency Physicians (www.acep.org), or American Association of Surgical Trauma (www.aast.org).
Does the plaintiff/defendent's medical history affect the allegation? A Legal Nurse Consultant can review the plaintiff/defendent's medical history, or clues to the medical history (notes about previous admissions, medication list, notes of previous physicians) that can relate and affect information about the allegation.
Are there missing medical records? A Legal Nurse Consultant can analyze whether medical records vital to the review of the allegation are missing, and are necessary to have for the case. For example: in a trauma/motor vehicle accident, all radiology records (xray, CT, MRI), lab reports, trauma physician consultation notes, nursing admission history and physical assessment notes are critical to evaluating appropriate standard of care to a case.
Is research necessary to correlate parts of the record, allegation and needed information about the case? A Legal Nurse Consultant can use nursing, medical and health information resources, including their own clinical experience and expertise, to research and review questions about a case. For example: cancer care, genetics, information about diagnoses and how they relate or don't relate to the allegations about a case.
Is a medical or nursing expert witness recommended? A Legal Nurse Consultant can assist in identifing recommended expert witnesses critical to giving expert testimony on a subject related to the medical allegation. A Legal Nurse Consultant can also help research, identify, review qualifications, as well as act as a liason to the testifying expert and assist in independent medical or forensic examinations on behalf of your case. Bringing clinical experience and expertise as well as experience in the healthcare systems, a Legal Nurse Consultant can bring a level of experience and perspective to the review and analysis of a medical legal case that is specific, clinically oriented, and critical when evaluating medical legal cases.
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