Remember when you were in grammar school and had to write reports? Remember how the students with the best handwriting always got better grades? When I clicked to that fact I concentrated on making my handwriting as neat as possible, hoping to score a bonus point or two. And except for my grades in conduct, I did a great job of accomplishing that goal.

First impressions are indeed lasting in all aspects of life and that fact is especially true for Certified Legal Nurse Consultants and their attorney-clients. My first subcontractors were my typist’s children. She had eight kids and I used seven of them in my business through the years. They became excellent assistants, pulling the results of my research from the shelves of the medical library. I personally taught each and every one of them the art of making flawless, straight copies of those research studies. Their work contributed to the first impressions I was making with my attorney-clients.

My typist and I were both equally attentive to the appearance of the reports. By the time the attorney sat down to absorb them he was ready. Nothing (no typos, bad formatting or messiness) was getting in the way of his receiving, accepting and trusting my opinion. Our attention to impression also contributed to those attorneys becoming long-lasting clients.

Today I critique a lot of work product from legal nurse consultants and sometimes my best advice is “Go back and create a new first impression, because if you don’t, you won’t get a second chance with that attorney.” Your legal nurse consulting business, like life, isn’t a video game. You won’t get a mulligan, do-over or a reset button on an attorney-client.

You rarely get a second chance, so make your first impression count for real the first time.

Success Is Inside!

“Finish it out” is the mantra of my trainer, Jerome. It doesn’t matter what exercise I’m doing, he’s always pushing me “Finish it out Vickie, finish it out.” If I’m doing a lat pull-down or a one-arm row, he doesn’t want me stopping short. Every exercise has a full range of motion and it’s easy to quit before contracting those muscles to their full potential. For example, if you’re doing one-arm chin-ups it’s easy to quit before your chin reaches the bar, and that’s exactly when I’ll hear Jerome chanting, “Finish it out Vickie, finish it out.” Okay, I really don’t do one-arm chin-ups (yet), but you get the idea, right?

When you’re writing a report or providing any of the other 32 CLNC^® services to your attorney-clients, ask yourself, “Have I finished it out?” I’ve critiqued more legal nurse consulting reports than I can keep track of and often my response is just like Jerome’s, “Nice start, but now it’s time to finish it out.” Always assess whether you identified and engaged your analysis as deeply as is required to win the case.

Keep an ear cocked for Jerome and me as we’re reminding you to “finish it out”.

Success Is Inside!

Citing references and formatting bibliographies are an important aspect of preparing your legal nurse consulting reports. This increases the credibility of the opinions you render to your attorney-clients. Here are seven tips to use when preparing your legal nurse consultant reports.

1. Follow the standard format for presenting references.
   • Textbook
     Schul, Patricia Dwyer. 2010 Nursing Spectrum Drug Handbook, Fifth Edition. New York: McGraw-Hill Professional, 2009

   • Journal article
     Jahromi, Afshin, Clase, Catherine M., et al. “Progression of Internal Carotid Artery Stenosis in Patientes with Peripheral Arterial Occulusive Disease.” Journal of Vascular Surgery^®. 50(2): Aug 2009, 292-298.
2. Provide a complete reference – including the author’s name, title of the article and journal or title of the book and complete publication information (volume number, page and year for a journal; city, publisher and year for a book). Be sure the publication information is accurate. Make sure your references are complete and accurate.
3. Put book titles and the names of journals in italics. Put article titles in quotation marks and not in italic type. You may be used to seeing the article and even the book titles with only the first words capitalized, but the standard format is to capitalize the first word and all major words in the title of an article or book. Do not capitalize “a,” “the,” “and” and short prepositions (unless they’re the first word in a title). Follow these formatting techniques and your reference list will be easier to read.
4. List your references in alphabetical order by author’s last name. In a reference with multiple authors, alphabetize by the last name of the first author listed. In a reference with no author listed, double check to be sure there’s no author on the work, then alphabetize by the name of the publishing organization.
5. When listing website references, if no author is listed, alphabetize by the name of the organization or title of the site (not by the URL).
6. Be sure website listings are current and correct. If you haven’t used a site in a while, recheck the link to make sure it still works and still takes you to the same information you used in formulating your report.
7. Group references by type of source – for example, textbooks, journal articles, websites.

Success Is Inside!

Technology today offers a variety of ways to present data to our attorney-clients as Certified Legal Nurse Consultants. Follow these 12 strategies the next time you write a medical-related case report to ensure your attorney-clients don’t miss a single salient point.

1. Present all similar data in columns, not in rows. When you place all related data – for example, all temperature readings, all hematocrits or all entries from the nurses’ notes – in a single column, the reader’s eyes can travel easily up and down to quickly compare and spot trends or discrepancies.
2. List events or other data in chronological order. If you’re dealing with late entries in the medical record, list the questionable entries in the stated order, noting in the Comments column that you suspect they were late. If a med given at 9:30am isn’t significant until the patient has a reaction to it at 12:00 noon, still list the medicine when it was given at 9:30; then in the 13:00 entry, refer back to the 9:30 entry, if necessary.
3. When creating lengthy chronologies, put data in similar order within each entry. For example, if most entries in your chronology summarize daily events including nursing notes, meds, medical orders, etc. list these in the same order each day. This makes each piece of data easier for your reader to find.
4. Be sure what actually happened is in the Events column and your comments about what happened is in the Comments column. Be careful not to mix up the two. Even when you’re summarizing or paraphrasing the record, you’re still describing the event – so put this in the Events column. Your opinions or notations on what was missing from the record, what was inconsistent, what was unlikely given the patient’s condition, what deviated from the SOC, etc. go in the Comments column.
5. If you have several tables in one report, use similar column widths and the same font and font size for column headings. This makes it easier for the reader to find and cross-reference data in different tables.
6. Give all figures, tables and exhibits meaningful titles. Also add descriptive captions to figures. Don’t just call a table “Chronology” – call it “Chronology of David Jackson’s Hospitalization at Memorial Oaks Rehab Center, 10/02/10-10/27/10.” This helps your reader to quickly find data that’s important to her and to understand the data she’s reading.
7. Refer to figures, tables and exhibits in the body of your text both by title and by number of letter. This makes it easier for your reader to find the data. Make sure your text shows why this data is included and its importance to the case – in other words, interpret your data for the reader.
8. Short tables can be incorporated into your text directly, unless they’re a part of a sequence of data which logically group together at the end of the report. If you’re putting a relatively short table in an attachment at the end of the report, expand the columns or enlarge the font size to make the best use of the space. Ultimately, the decision on where to place tables, figures and other data is based on where the reader can find it the quickest.
9. Tables, especially longer ones, are easier to read and follow when you use grid lines. Keep the grid lines thin and light to avoid distracting from your data.
10. For tables longer than one page, set them up so that the title and heading rows repeat on each page.
11. Optimize column widths in tables. If you have extensive Comments, make that column wider. If your Event descriptions are longer, give that column more space. Wrap text when needed. Generally, put Date/Time in one column and make it as narrow as possible to save space. If your entire chronology takes place on one day, you don’t have to restate the date for every entry – just be sure the date is part of the title of your table and use a Time column instead of a Date/Time column.
12. Don’t be afraid to use landscape layout if that will help you present the data more compactly or more effectively. Often landscape works best when you have numerous columns.

Now that you know these 12 strategies to present to your attorney-clients in an easy to understand format, it’s time to go write that report.

Success Is Inside!

P.S. Comment and share your favorite formatting tips.

Everything you put into a comprehensive report as a Certified Legal Nurse Consultant should be there for one purpose and one purpose only – to inform your attorney-client of the information necessary to win the case. Every opinion, every paragraph, every table, every exhibit, every reference should serve that purpose. Your job as a Certified Legal Nurse Consultant is to make sure the purpose of each part of your report is clear to the attorney reading it. After all, if the attorney has to figure out what you mean by something or why you included something, he might as well do the work himself.

Your attorney-client will be a lot more likely to call on you again and again for comprehensive reports if you make his job easy by following these strategies for creating first-class comprehensive reports.

1. Identify the attorney’s preferences
   The attorney-client may not always know what he needs but often before you provide what you know he needs you may have to first give him what he thinks he needs. Inquire about the intended purpose of the report, potential users of the report and any preferences for format or design. This will accomplish two things in advance:
   • You can more easily judge the format (chronology, narrative, etc.) and amount of detail required for specific portions of the report.
   • You and your attorney-client both know what is being requested, which decreases the risk of providing an unwanted, unnecessary or surprise work product to an attorney.

   This approach will never fail to earn you positive feedback.

2. Keep it real
   Try to learn how much medical knowledge and experience the attorney has with similar cases. For example, if an attorney handles a large number of failure-to-diagnose myocardial infarction (MI) cases, you may not have to include an extensive discussion about anatomy or physiology because the attorney may already be familiar with this information. Instead, tailor this portion of the report to the specific case issues regarding this specific MI. Conversely, if an attorney does not have extensive medical malpractice experience with MI cases, you may devote a section of the report to a review of anatomy and physiology, disease process and current treatment protocols. Don’t assume the attorney knows how this information applies to the case. Always explain how it applies both to the case and the client the attorney is representing. Assessing the attorney’s medical knowledge also guides you in knowing how much you need to translate the medical record and medical terminology.
3. Do Your Research Before You Start Writing
   Review applicable standards of care and scientific literature and identify the sources you will use before drafting the report. This time-saving procedure helps you organize your thoughts and determine where to include the relevant resource material.
4. Recycle your research from other reports for greater efficiency
   Depending on the type of case, you may be able to re-use sections from previous legal nurse consulting reports or summaries prepared for similar cases. For example, in two cases involving delay in diagnosis of myocardial infarction or chest pain evaluation, the standards you applied to the first case may be relevant to the second case. Review your other reports on similar cases to determine if any of the material applies to your current case before starting the report. Of course, there is no “one size fits all” approach to report writing. Each case must be analyzed individually, but occasionally, you may be able to avoid duplicating your effort and research.
5. Create an outline to ensure you cover all important issues

   Outline your opinions as well as your plan for presenting them.

   A comprehensive report includes some or all of the following:

   • Letter to the attorney.
   • Cover sheet.
   • Table of contents.
   • List of records, documents and tangible items reviewed and examined to date.
   • List of significant players.
   • Summary of the case or summary of relevant information.
   • General and specific deviations from, and adherences to, the standards of care (malpractice cases only).
   • Summary of scientific theory, research and standards.
   • Additional discovery.
   • Definitions of all medical terminology and abbreviations in simple terms.
   • Potential opposition arguments.
   • Conclusions.
   • Follow-up questions.
   • Recommendations.
   • Reference list.
   • Summary of testifying experts’ opinions.
   • Abstracts of pertinent articles
   • Copies of relevant scientific literature.
6. Apply a systematic approach to keep chronologies reliable
   Even a small error in date or time can influence the rest of your report. To minimize these costly typos, enter data from one complete section of the chart before moving on to another section. For example, start entering data with nursing and vital sign graphic entries because these data are usually dated and timed and occur more frequently than entries by other healthcare providers. Then, enter all lab report data in the appropriate order before moving on to radiology reports. It may then be possible to place undated or, more often, untimed physician’s progress notes and orders based on the chronology you have already created. In putting the pieces of the puzzle together in this fashion, you may identify other important issues to address in your evaluation and report.
7. Customize the report format to meet the attorney-client’s needs
   Avoid using the same format and length for each and every case. You may wind up including information that is not cost effective or relevant. Instead, write a report that meets your attorney-client’s needs and presents the information in the most logical manner. If you have difficulty organizing your thoughts or facing a blank computer screen, use a computer software program that can help with formatting case reports and chronologies. The key, however, to producing an effective work product is not only format and visual appeal, but the content, analysis, and conclusions you draw. This is the value you bring to case analysis that other members of the legal team are not qualified to do.
8. Break up the topics
   Break up long paragraphs. Stick to one topic per paragraph, just like your English teacher taught you.
9. Use lists to communicate a sequence of items
   To make groups of related points clearer, use bulleted lists. If the sequence of items is important, number the list instead of using bullets, e.g., number a sequence of steps that came or should come in order.
10. Format consistently throughout the report
    Refer to dates and times consistently. You may be used to “military” time, but if your attorney-client isn’t, help the attorney out by also indicating the standard. If using a.m. and p.m., choose a standard format for this and stick to it. Likewise for dates, pick one way of formatting dates and use it throughout the report. Vickie Milazzo Institute standard is the mm/dd/yy format – i.e., March 5, 2010 is formatted 03/05/10. You may choose to spell out dates in the body of your report and use a numerical format for tables.
11. Respect your attorney-client’s intelligence
    When writing your legal nurse consulting report, explain a medically complex situation with the preface, “This is the way I would explain it to a jury.” This allows you to get down to the attorney’s level without insulting his intelligence.
12. Use a cover letter
    If the report is comprehensive, be sure to include a cover letter introducing the report, restating your assignment briefly, summarizing your bottom-line opinion, and conclude by thanking the attorney-client and offering to  provide additional CLNC® services on this or future cases. Also include a table of contents listing the major subheadings within the report.
13. Clarify medical terms and abbreviations
    Either define medical terms and abbreviations on the spot (if few terms are used) or provide a glossary at the end of the report (if numerous terms are used). Whenever you use an abbreviation for the first time, unless you’re absolutely sure your attorney-client is familiar with it (e.g., MD, RN), spell out the term then put the abbreviation in parentheses – for example, advanced cardiac life support (ACLS). Then on subsequent uses of the term, you can simply use the abbreviation. Most acronyms can be formatted without periods. Remember, you’re so familiar with many medical acronyms, you don’t even notice them – but if your attorney-client has to stop and look up a term or puzzle it out, he won’t appreciate your wasting his time.
14. Correctly shorten units of measure
    Use consistent notation for units of measurement throughout the report. In general, abbreviations for units of measurement do not require periods (unless they’re used at the end of a sentence), nor do they require adding an “s” for the plural. For example, 1.5 cc, 0.5 mg, 127 lb (not 127 lbs), etc.
15. Make your report shine by setting it aside
    If time allows, put the report aside for one or two days before doing any final proofreading or editing. Check the report for overall continuity and format, then review each paragraph for content, relevancy and grammar. Finally, analyze each sentence for grammar, proper placement and always check spelling.

    Be sure you deliver what you promised. Before you submit your final report, go back over your notes and the original letter from your attorney-client. What did the attorney ask for? Did you include this information? In your cover letter for your report, do you state that you’re including requests for production, a list of references or a glossary? Make sure it’s all there in the final draft.

Your CLNC^® report will linger in the case file long after your meeting with your attorney-client. It may travel to other law firms or co-counsel, and will be used by many members of the legal team before the case concludes. What type of first (and sometimes, only) impression are you leaving with your attorney-clients and potential future clients? Make every report the best ever by paying stellar attention to detail.

Success Is Inside!

As a Certified Legal Nurse Consultant, you will frequently give attorney-clients verbal opinions on medical-related cases, but you will also render written opinions on cases. When it’s time to sit down and compose your written report, you want to do so fast and you want that report to be the best it can be.

I love writing reports. Let me qualify that statement. Once I’m writing, I love writing. Sometimes I’m challenged to get into the writing and I will find all kinds of excuses to avoid getting into the writing process – urgent emails, seminar preparation, the toilets need cleaning…you get the idea.

Here is a five-step writing process for composing reports of all lengths from brief to comprehensive. These five steps will help you jump in fast and never again choose a toilet over a report.

Step 1 – Start with a Preset Pattern

The pattern-seeking logical brain likes to know the order of things, so start with a preset pattern for the result you want to achieve. Picture the result. Define the result. Walk through the result mentally. Look at one of the Institute’s sample reports to use as a template. If you have a model, image or pattern in mind, it’s easier to get started.

Step 2 – Stuff Your Brain

Stuff your brain with all the information you can get on the subject. Research relevant standards and scientific literature. Talk to essential players such as the attorney, a CLNC^® subcontractor, a plaintiff or defendant. Don’t focus on formulating opinions; just take it all in until your brain feels thoroughly saturated. The more information you take in and the more you absorb, the more likely you are to reach the correct conclusions.

Step 3 – Buzz Off

Take a break. Sleep on it, when possible. At least take a walk. Incubation is an essential step in any creative process. During this time, think about anything except what you’re working on. Likewise, capture those brilliant thoughts you have when you’re not supposed to be thinking about the case report. I find that I reach my best analysis after sleeping on a case or situation overnight (not at my desk). Sometimes I’ll reach my “eureka” moment in the shower or while cleaning that toilet.

Step 4 – Pour It Out

This is a no-wrong-answers brainstorming dump. Let the creative right brain take over to synthesize the material and develop a raw first draft. Suspend judgment. Don’t get it right, get it written.

• Put on slow (60 beats a minute), low-volume music. This will stimulate your mind without the overstimulation of Lady Gaga-esque dance music.
• Turn off the phones, children, spouses and other interruptions (no email either).
• Spill the beans. Dump everything out of your brain without editing, simply write, type or talk into a recorder.
• Don’t think about what you’re doing; ignore misspelled words and incomplete sentences. They’ll only move you from productive to editing mode. If you catch your left brain trying to muscle in to add logic, push it away and keep pouring out the raw material.
• Go until you’re empty. Spend 20-50 minutes, or until your brain feels drained and the ideas dwindle to nothing (it may happen sooner).

Repeat this brain dump as many times as needed with breaks in between. If you do take a break, make sure it supports the creative process. For example – grabbing a bite to eat, taking a walk or stretching, all support your goal by keeping the creative process free (unless you’re making a Dagwood sandwich). Interruptive processes like checking email and voicemail have the potential of disrupting your goal big time by focusing you on other issues or problems.

Step 5 – Structure and polish

Go back and assess your work product to see whether you agree with the content of what you’ve written. Ask yourself, have you said all you need to say? Is your opinion the same? If not, make the necessary change. When you’re done, move to structure and polish. Now it’s time to haul out the left brain and set it loose to create the stellar report you want to produce.

• Select the ideas that work.
• Arrange them in a logical order that fits the pattern your left brain thinks will work best.
• When you’re 90% satisfied, lay it aside (overnight, if possible). Let that “mulling” process think it over once more.
• Return to your report later for a final polish.
• Finally, proof a printed copy of the report.

Even when you have only an hour for the entire job, this process works (just take shorter breaks). Encourage both sides of your brain to do their best work, and the result is a fresh, creative approach presented in a pattern that makes sense – to you and to others.

Success Is Inside!

One of my favorite things to do in Austin, Texas, other than eating at La Condesa, is walking the trail around Lady Bird Lake. It’s peaceful and relaxing being by the water. You get to see aquatic wildlife and, if you’re fast enough, sometimes you can catch a glimpse of a turtle or two sunning themselves on the bank. On our last trip, while walking the trail, Tom and I had a pretty good laugh over a warning sign we ran into on the trail, obviously put in place by a well-meaning worker from the City of Austin’s Public Works Department. It reads: SIDEWALK CLOSED, USE OTHER SIDE.

While the sign, does indeed seem to point out the obvious, it made me think about legal nurse consultants writing reports for attorney-clients. Whether you’re writing a brief or comprehensive report, you need to point out the obvious, salient points from the medical record for that attorney-client. This includes deviations from and adherences to the standard of care. As a Certified Legal Nurse Consultant, you’re the expert on the medical record and you are the one who must point out the obvious. The attorney is the expert on the law. While you may work with an attorney or two who knows enough about medicine to open a practice as a doctor (unlicensed), the majority of attorneys do not. Those attorney-clients depend upon you to tell them what they need to know about the treatment, injury and actions of the parties. This includes pointing out the obvious.

As a nurse, you have a tremendous amount of knowledge about nursing, medicine and just about every aspect of healthcare. This brings its own dangers. Sometimes incidents, deviations or lapses in care that are obvious to you in their effect on the case, won’t be obvious to your attorney-client. Certainly you need to write your legal nurse consulting reports to the skill level of each particular attorney-client, but, at the same time, you don’t want to overestimate their ability to see and understand the obvious. You can’t assume that the attorney will recognize the importance of a critical deviation if you give it the same weight as every other deviation you address in your report. What’s obviously important to you, may not be obvious or important to the attorney-client. If you don’t believe me, think of some of the obviously important things you point out to your spouse (“Honey, remember what happened last time you tried to rewire a lamp? I think you should unplug it first. Or Honey, don’t let the baby get too close to that alligator.”).

If something is obvious to you and importantly obvious to the case, point it out. Tell the attorney-client why it’s important. Don’t assume they’ll pick up on it themselves. Do this religiously and you just might keep them from getting soaked in court or in a lake.

Success Is Inside!

A common question I get from Certified Legal Nurse Consultants is whether or not you should supply your legal nurse consulting work product to attorney-clients as a Microsoft^® Word document or as a paper printout.

I’ve never been a fan of letting an editable document out of my control. Not only do you run into issues where different users/recipients have different versions of Word software and suffer formatting issues, but you also have the very real concern that your words may be edited and end up not being your own. That is especially unsettling to me if my name is on the document or the document is on my letterhead. Attorneys, like everyone else, prefer to have paper printouts to work from so that we can highlight, make notes, etc. We also like to be able to reproduce a clean copy after we ruin the first one by writing all over it or dripping Russian dressing from our Reuben sandwiches on it while we eat lunch at our desks.

There is a way to solve everyone’s needs (beside offering extra napkins). Send the document to the attorney in portable document format (PDF), a file format created by Adobe Systems back in the early 1990s. Any document created as a PDF will maintain its formatting no matter what printer is used to print it or what computer is used to view it and you can also restrict whether or not someone can cut and paste or edit the document. Most people use the free Adobe^® Reader to view PDF files (which restricts cutting/pasting) but to create PDFs, you once needed to buy a full or professional version of Adobe Acrobat which will integrate into Microsoft Word 2007.

A free alternative is Bullzip PDF Printer, a program that allows you to create PDF documents from just about any Microsoft Windows program, including earlier versions of Word. Bullzip PDF Printer installs and operates as if it is a printer. You simply print to Bullzip PDF, supply the output file name and it will create the PDF file for you. Anyone with the Adobe Reader can open, view and print the file and it will look exactly as you intended.

Simply set your PDF document properties (protection level) and email it to your attorney-client. Now you can sleep without worrying about what’s happening to your legal nurse consulting work product after it has left your control.

Keep on techin’,

Tom

When you’re writing reports for your attorney-clients’ medical-related cases, one of the most important principles, no matter the size or type of report, is that if you provide theory, you are sure to provide application also. In other words, the theory must not only relate to the case, but you must explain the actual application of the theory to the case at hand. Theory alone is not enough. Keeping your reports based in the “real world” will make the real attorneys you consult with really appreciate you and your legal nurse consulting reports.

Success Is Inside!

The original Impressionists were considered radicals in their day as they departed from what was considered the “old-school” of artists. Time after time, impressionist painters would submit their work to juried art shows but their paintings would be rejected in favor of lesser artists who painted in the “approved” style of the times.

In order to exhibit their own works, these revolutionary artists rejected the establishment and formed their own society of painters – the Société Anonyme Coopérative des Artistes Peintres, Sculpteurs, Graveurs (Cooperative and Anonymous Association of Painters, Sculptors, and Engravers). Their first show was met with a firestorm of criticism and the term “Impressionist” was given to their artistic style as a derogatory term. The artists chose to adopt this derogatory term “Impressionist” and proceeded to make art history.

The “Impressionist” school captured the scenes they were painting without the strictures placed upon painters by the “Realism” school that was dominant at the time. They focused, or unfocused, on a new way of painting light into scenes of everyday life, rejecting the minute details of realism. When you look at an Impressionist painting up close, there is no detail – there are only short thick strokes and unmixed colors. When you stand back from the painting you see, with a realism not present in the “Realist” paintings, the diffused sunlight on a haystack, people strolling down a boulevard or partying on a Sunday afternoon in a park. The works come alive from a distance.

When an attorney-client is presenting a case to a jury, too many details can bog it down, distracting the jury and leading them down rabbit trails. Your job as a CLNC^® consultant is to help the attorney present the picture with the broad strokes and bold colors needed to show the case in its best light. Sure the underlying details will need to be there to back up your opinions and the attorney-client’s case, but sometimes it’s best to present an Impressionist view of a case to an attorney-client and then to the jury before breaking it down to the details.

They say you never get a second chance to make a first impression. What sort of Impressionist impression are you making on your attorney-clients?

Success Is Inside!