Medical Records for AttorneysALI-ABA, 2001 - 427 σελίδες |
Περιεχόμενα
The Hospital Chart Overall Organization and Elements | 9 |
Consent for Admission and Other Consent Forms | 15 |
b The General Consent Form in a Hospital Record | 16 |
2 Placement of Catheters or Special Lines | 17 |
4 Lumbar Puncture Spinal Tap | 18 |
Emergency Room ER or ED Documentation | 19 |
b How To Find the Emergency Room Documentation | 21 |
c Use of AllinOne Forms To Record Emergency Room Care Emergency Department Record | 22 |
Figure 230 Authorization for HIVRelated Information New York State | 193 |
Figure 231 Distinguishing XRay Copies From An Original | 199 |
Figure 233 Discharge Summary In DRG Code | 217 |
Special Documentation Sections in the Hospital Chart | 221 |
Figure 32 Anesthesia Record for Operation Typical Format | 227 |
Figure 33 Intensive Care Unit ICU Flow Sheet | 234 |
Hospital Clinic Notes | 245 |
Figure 41 Hospital Clinical Note Typical Format | 248 |
Figure 22 Emergency Department Form | 23 |
2 Stabilize | 25 |
5 Order Consults or Referrals as Needed | 26 |
7 The Ambulance Call Sheet and Reconstructing the Timing of Emergency Room Care | 27 |
Police Aided Reports Motor Vehicle Accident Reports | 29 |
Figure 24 Triage Form | 30 |
10 Emergency Room Nursing Notes | 32 |
The Concept of an Appropriate Disposition | 33 |
f How To Tell From the ER Record Who Was Responsible for Ordering the Appropriate Disposition | 35 |
The Time Frame for Planned Followup Often at Issue | 36 |
2 Admission to the Hospital From the ER | 37 |
Figure 26 Patient Discharge Instruction Sheet | 38 |
4 Patients Leaving the ER Against Medical Advice and Patient Noncompliance With Discharge Instructions | 39 |
5 Why Emergency Room Presentations Result in So Much Litigation | 41 |
Figure 28 Admitting History and Physical Note | 44 |
Figure 29 Attending Versus Resident | 72 |
Figure 210 Attending Physician and Resident Functions Distinguished | 84 |
Figure 212 Order Sheet Typical Format | 94 |
Figure 214 Fall Risk Assessment Typical Form | 109 |
Figure 217 Frequently Litigated Consult Scenarios | 126 |
Figure 219 Nursing Admission Assessment | 133 |
Figure 221 Temperature Chart | 140 |
Figure 224 Laboratory Slip Sample | 149 |
Figure 226 Complete Blood Count Diagram | 156 |
Figure 227 Arterial Blood Gas Lab Slip | 177 |
Figure 229 Electrocardiogram Sheet EKG or ECG | 187 |
The Doctors Office Chart Typical Organization | 251 |
Figure 51 AlteredTampered Physicians Note | 256 |
Prenatal Care The Standard Visits and Tests | 261 |
Figure 61 First Obstetrical Note Good Note Typical Format | 265 |
Figure 63 Sonogram Report Typical Format | 271 |
The Overall Structure of an Obstetrics Chart | 277 |
Figure 71 Fetal Monitoring Strip Sample | 279 |
By the FourDigit System | 286 |
Figure 75 The Ischial Spines In Relation to Station | 293 |
Figure 77 Nursing Labor Progress Notes | 300 |
Figure 711 Obstetrical Anesthesia Record Typical Format | 312 |
Figure 713 Pathology Report for Normal Placenta and Cord Sample | 322 |
Figure 714 Fetal Monitoring Strip | 328 |
Figure 715 Records To Establish MinuteByMinute Chronology | 340 |
Getting the Relevant Medical Records | 341 |
Figure 81 Medical Records Authorization for Patients Own Records | 344 |
Figure 82 Cover Letter to Accompany Medical Record | 345 |
Understanding the Different Types of Doctors | 355 |
Table 91 The Different Types of Doctors | 356 |
General Definition | 362 |
The Disease Management Movement and Development | 369 |
Figure 101 Common Disease Management or Protocol Situations | 374 |
Trends Toward Electronic or Paperless Medical Documentation | 377 |
Figure 111 Nursing Care Plan | 385 |
Συχνά εμφανιζόμενοι όροι και φράσεις
ABA ALI ABA abbreviated ABGs abnormal addition admission admitting history admitting physical anesthesia anesthesia record antibiotics Apgar score assessment Attending physician attorney basic blood cells body cesarean section chest clinic Code complete blood count condition consult CT scan deceleration described diabetes diagnosis discharge disease doctor documentation Emergency Room evaluation evidence example expert fetal monitoring strips fetus Figure findings fluid given hospital chart imaging study indicate infant infection interpretation issue known lab slips labor medical malpractice medical record medicine mother myocardial infarction normal nursing obstetrical obstetrician Operative Report overall oxygen pain particularly Pathology patient pediatric performed physical exam placenta plaintiff platelets potential practice pregnancy prenatal prior procedure progress notes pulse radiologist radiology relevant require resident respiratory responsible risk significant sonogram specialty standard sub-Board surgery surgical tion tissue transfusion treatment typically vital signs white blood cells X-ray