medical records

Screening medical-related cases is one of the most important legal nurse consulting services you will provide as a Certified Legal Nurse Consultant. Not only is it one of my favorite CLNC^® services but it is the first CLNC^® service you usually provide for new attorney-clients. Do it well and the attorneys keep coming back for more. Here are 16 screening strategies to keep your attorney-clients coming.

Stay Focused on the Essentials

1. Give the attorney an objective, candid and honest opinion without regard for what you think the attorney wants to hear. Put aside interests in personal gain (e.g., more billable hours) and focus only on what is ultimately best for the attorney, the client and the case.
2. Discuss the issues and theme of the case with the attorney-client and ascertain the date of the incident (when known) to help you focus quickly on the important events. If the case has been filed, request a copy of the complaint or petition. You will screen many cases in which the attorney knows little about the facts and has formed no opinion. If the attorney does have an opinion and you believe he is focusing on the wrong issues or your opinion is different, be sure to communicate your reasoning right away.
3. If you do not have time to do the screening as soon as you receive the case, at least read the cover letter and scan the medical records. This helps you to establish deadlines, determine the basic issues of the case and assure you have all the necessary records. If relevant records are missing, inform your attorney-client immediately.
4. Scan all relevant medical records and, where appropriate, note important observations and opinions. Avoid excessive writing at the screening stage, especially if you haven’t yet identified the essential issues and themes of the case. Your goal at the screening stage is to be efficient, and until you’ve reviewed all relevant records and identified key issues, it is very easy to go down unnecessary rabbit trails.
5. Use the screening form to track all possible defendants, types of experts needed, additional documents needed and recommended research. When you give your screening opinion to the attorney, you can incorporate some of these into recommendations for the next indicated steps.
6. Screening a case is similar to reading a mystery novel. You may even be surprised by the outcome because the focus may shift from something obvious, like a patient fall, to a less obvious issue, such as medication administration or safety policies and procedures. As new and more relevant issues arise, determine their significance and how they impact the essence of the case.
7. Do not overlook the obvious by overanalyzing the records. Likewise do not assume that the issues will automatically jump out at you. If you become overwhelmed by the task at hand or the volume of medical records, walk away for a while, or a day or two, then come back fresh and start again.
8. Do not assume the case has no merit simply because a physician reviewed the records and found no merit. Physicians tend to limit their reviews to doctors’ records and in so doing, they often miss vital information. For example, many MD experts do not review the nursing records and often it’s the nursing notes that shed the most light on what really happened to the patient. Always review the records completely and look for discrepancies in documentation by different providers.
9. If you were hired by the plaintiff attorney, look at the case from the defendant’s viewpoint. (What are the defenses or rationales in this case?) If you were hired by the defense attorney, look at the case from the plaintiff’s viewpoint. (What went wrong, if anything? Could anything have been done differently? Were any standards of care or practice guidelines breached?)

Efficiency Saves You Time and Saves Your Client Money

10. Don’t organize the medical records before you screen and you will save valuable time in the initial review process. If organizing the records is necessary before screening, do not organize them for comprehensive review and analysis, but organize only with the objective of making screening easier.
11. Do not do a formal report during the screening stage – just complete the screening form to facilitate communicating your opinion clearly and concisely. More comprehensive reports are only indicated once you have communicated your screening opinion and both you and the attorney agree that a comprehensive review and analysis of the medical records is indicated.
12. Access relevant healthcare references as needed while you are reviewing but don’t overdo it at this stage. Unless you need some piece of information before you can move on, make a list of topics to search on the Internet and do all your searching at once. This will keep you focused as you read through the record. Narrow your searches to match the factors in your particular case (e.g., octogenarian, female, femur fracture, mortality). Be sure to research any articles and publications authored by all the relevant players in the case.
13. Consider subcontracting the screening if the issues are outside your area of expertise. Make the decision to subcontract quickly, then act on it. Don’t wait until you need a CLNC^® subcontractor to try to find one. Develop a pool of CLNC^® subcontractors who are ready to respond to your needs. All successful CLNC^® consultants know what they don’t know and wisely tap the expertise of their peers.
14. Use a magnifying glass (buy the best one you can afford) so you can read those little squiggles and impress the attorney with your knowledge of hieroglyphics. You may determine the outcome of the case by being able to decipher something illegible to the average eye.
15. Keep a calendar of the year in question close by. Look for weekends and holidays when short staffing is common.
16. Pay particular attention when operative notes, admission history and physicals, discharge summaries and autopsy reports are dictated and transcribed. If an unusually long period of time elapsed between the event and the transcription, note that for future consideration.

Use these 16 strategies to make screening medical-related cases one of your most popular and satisfying CLNC^® services. Keep your attorney-clients coming back for more.

Success Is Inside!

My most memorable case occurred when I testified for the very first time. I had been a Certified Legal Nurse Consultant for about a year. The case was a will contest. The client was the daughter of an elderly woman who had passed away in a skilled facility. About 72 hours prior to her death, the son (the client’s brother) had the will altered so that he would inherit most of the estate. The changes to the will were made by an attorney. The son then took the will to the facility and had his mother sign it with a notary (a friend of his) present and another witness (his sister-in-law). The estate was worth around $1,000,000.00.

My attorney-client hired me to review the medical records to search for evidence that the deceased was under undue influence when she signed the second will (based on the records and that 72-hour window). I reviewed the records and prepared my report. I found the mother was confused, too weak to hold a pen by herself, under the influence of strong sedating medications and hypoxic.

My attorney-client decided that his case depended on my assessment of the mother and her mental state during the time of the second will signing based on my findings in the medical records. I was called to testify. I was nervous so I rehearsed the night before.

There was a jury present to hear the case. The opposing attorney, of course, tried to tear me apart but I looked at the jury and relayed facts from my report in terms they could understand. He could not trip me up no matter how hard he tried. I testified that when the mother signed the second will, she had low oxygen saturations in the 70s and 80s with use of supplemental oxygen (the patient was a DNR by her choice). The impact of hypoxia on the brain, the effects of large doses of morphine and Ativan IV in regards to sensorium, the fact she had to be fed as she could not hold a fork or spoon and probably not a pen on her own, and the nursing and rehab staff repeatedly charted the patient was confused and disoriented painted a picture of her mental state. I also pointed out the doctor who testified earlier that the client was alert and oriented was not the doctor who had seen her last based on the signatures in the chart. Furthermore no physician had assessed her during the 24 hours prior to her signing the second will. Thus, the testifying physician, although he was the PCP, would not have had first hand knowledge of her mental status at the time in question as did the nursing staff and rehab staff who actually assessed her during the time frame in question.

The final question that the opposing attorney asked was, “How much does Mr. M. pay you for your services?” I answered his question and he then said, snickering with a smug look on his face, “That is a little steep, don’t you think, for a nurse?” I started to reply and he cut me off. I looked up at the judge and asked calmly if I could answer the question. The judge told me to go ahead. I proceeded to tell the attorney that I had 24 years of nursing experience and had taken care of hundreds of dying patients. I explained what a CLNC^® consultant does and how I received my training, and I offered to give the opposing attorney my contact information. The jury was smiling at me. I then left the court room.

Later that evening I received a phone call from my attorney. He said, “You were fantastic, we won. The jury said your testimony sealed the case in our favor. By the way, on my way out, I patted Rob (the opposing attorney) on the shoulder and told him that is why I pay your consulting fee. He wasn’t laughing anymore, but fuming mad.” The daughter received her half of the estate as directed in the original will and the court determined the mother was not competent and was under undue influence when she signed the second will thus it was null and void. I have since worked for the opposing attorney.

P.S. Please comment and share your most memorable CLNC^® case.

Guest Blogger Profile

Stephanie D. Stanley, RN, CLNC owns SDS Legal Nurse Consulting Services, LLC in Virginia. Stephanie consults with attorneys on a variety of medical-related cases.

We all have goals of saving money. Do you want to learn a great way to save over $400 in 2009? Save yourself the expense of a dedicated fax line. If you don’t use your fax machine that often, or if you send more faxes than you receive, you can buy a cheap Duplex Wall Jack Adapter ($2.51 on Amazon.com) and plug your phone and fax machine into that adapter.

With the adapter, both your home or office phone and fax machine are on the same line. Next, set your fax machine to “Manual” and call the phone company and cancel the old dedicated line. On the manual setting you can send faxes at any time and the fax won’t answer when your attorney-clients call, your regular answering machine will. If you need to receive a fax, you can activate the fax – but you have to be there to switch it on, which may be inconvenient.

If you want to keep the full functionality of the fax machine, add a Command Communications Comswitch 5500 3-Port Phone/Fax Modem Line Sharing Device ($50.24 from Amazon.com) between the wall and your phone and your fax machine. This neat little device senses the type of incoming call (probably from the fax screech) and directs it to the appropriate device.

You’re probably spending $38/month or better on your dedicated fax line so this system will pay for itself in 2 months!

Now that you’re saving money hand over fist start planning on your next equipment purchase: A Fujitsu ScanSnap S510 ($399 on Amazon.com). This scanner is the size of a Barbie^® Lunch Box and it’s fast. Feed your papers in like a fax. It quickly and easily scans both sides of a document directly to a specific application such as Word^® or Excel^® or, into a searchable PDF for easy filing, emailing or other communication. There’s even one for Mac users!

Now you can start scanning your reports, medical records and other paperwork and clean out those filing cabinets. It also comes with a full version of Adobe^® Acrobat^® which lets you edit your documents after scanning.

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This sure beats faxing and is great when you’re sending contracts or other reports to an attorney and don’t want to provide them with the native Word^® document.

See you next Tuesday!

Tom