5 Common Legal Nurse Questions Regarding Medical Records

There are five common questions asked by CLNC® students regarding medical records related to legal nurse consultant jobs. Read on for the questions and the answers.

  1. Do I request medical records directly from a healthcare facility or provider on behalf of an attorney?I don’t recommend you request documents for an attorney-client as that is the attorney’s function. The attorney’s office will have a procedure they adhere to in obtaining medical records to assure that all requests are made in accordance with applicable laws.
  2. I’m reviewing a case for an attorney-client, but there are missing records. What do I do?Provide a list of the missing documents to your attorney-client. Let the attorney know you need to analyze these critical records to reach a definitive conclusion.
  3. I’ve requested additional medical records and still have not received them. What next?Decide if you can complete an initial report with the information you have on hand. If so, include in your report, the specific missing documents that require review or further investigation to reach a definitive conclusion on the case.If you are unable to create a report based on the records and information you have, contact the attorney-client and advise the attorney that you will complete the report as soon as the missing records have been received.
  4. Do I return the medical record to the attorney once I’ve completed my review?If you have printed your own copy from an electronic version, you do not have to return the records to the attorney. If the attorney sent you a hard copy of the medical records, ask the attorney if she would like you to hold the records for future consultation or return the records. If the case has concluded, a third option is that the attorney might want you to shred the records. You should maintain a copy of all your notes, reports and correspondence once the case is resolved.
  5. How long do I keep files after a case is closed?Once the case is resolved, maintaining notes and correspondence for five years is appropriate. However, I recommend that you keep all reports so you can refer to them for future cases.

Before you submit your next mentoring request, refer back to this blog post and review these 5 common legal nurse questions regarding medical records. You may find the answer here.

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P.S. Comment here and share your standard processes for handling medical records.

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*The opinions and statements made by Vickie Milazzo, the founder of Medical-Legal Consulting Institute, Inc. are based on her experiences and expertise, should not be applied beyond the specific context provided, and do not guaranty or project actual results. Vickie Milazzo is no longer involved in the operations or management of the business, but is involved as an independent education consultant.

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