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Detection
of Tampering with Medical Records Toolkit
For Plaintiff Attorneys,
Legal Nurse Consultants, and Paralegals
Patricia
W. Iyer, M.S.N, RN, LNCC
96 pages
2005, Med League
Price: $60.00
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Table of Contents
Whether you are an attorney or legal nurse
consultant, you will gain from reading this toolkit. Expert
Patricia Iyer presents
information on detection of tampering with medical records
in a practical manner. You’will learn the legal implications
of tampering andhow to detect tampering. Included are many
actual examples of altered records.
The 96 pages of content cover these topics:
- substandard charting
- suspicious charting
- definitions of spoliation
- spoliation inference
- implications of spoliation
- organizing medical records
- techniques for tampering with medical
records
- detection of tampering
- strategic decisions
- defense of spoliation claims
Also included are three checklists:
- Is there reason to believe that the medical
record may have been tampered with?
- A blueprint for organizing medical records
- Strategies for detection of tampering
with medical records
as well as 35 slides of examples
of altered records and descriptions of almost 30 legal
cases involving tampered records.
The material in this toolkit has been assembled
over years by an experienced legal nurse consultant and author
of two chapters on tampering with medical records:
Patricia Iyer, Nursing
Home Litigation: Investigation and Case Preparation, Second
Edition, 2006.
Patricia Iyer, Barbara
Levin, and Mary Ann Shea, Medical
Legal Aspects of Medical Records, 2006.
Table
of Contents
1.
Introduction
2. Substandard Charting
Incomplete charting • Untimely charting •
Illegible handwriting • Incorrect charting
3. Suspicious Charting
Detailed addenda • Duplicate information
4. Definitions of Spoliation
5. Spoliation Inference
6. Implications of Spoliation
Effect on the case • Jury charge • Effect
on the healthcare provider: Insurance coverage, Regulatory
agencies and privileges, Criminal/civil offenses • Tampering
by attorneys • Remedies for the person harmed by spoliation
7. Organizing Medical Records
Compiling records • Other documents and items
to review
8. Techniques for Tampering With Medical Records
Adding to an existing record at a later date •
Placing inaccurate information into the record • Omitting
significant information • Changing numbers • Rewriting
the record • Destroying records • Adding to someone
else's notes
9. Detection of Tampering
Incident report • Examples of allegations: Pressure
ulcers, Malnutrition and dehydration, Physical and sexual
assault, Falls and fractures, Elopement, Birth trauma, Surgical
errors
10. Strategic Decisions
Document examiners • Discovery requests • Use
of interrogatories
11. Defense of Spoliation Claims
Elements of proof • Proactive approach with defendants
• Credibility
12. Summary
References
Checklist 1: Is There Reason To Believe That The Medical Record
May Have Been Tampered With?
Checklist 2: A Blueprint for Organizing Records
Checklist 3: Strategies for Detection of Tampering
Related
products:
With Patricia Iyer as author,
editor, or contributor
Falls
Handbook
Medical
Legal Aspects of Medical Records
Medication Errors video
Medication Errors Toolkit
Nursing
Home Liability video
Nursing
Home Liability Toolkit
Nursing
Home Litigation: Investigation and Case Preparation
Paralysis
from a Medical Error
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