Medical Records A-Z: What attorneys need to know (2024 Edition)

Jean K. Cooper, MSN, BSN, RN, LNCC | Benchmark Legal Nurse Consulting, LLC.

Jean K. Cooper, MSN, BSN, RN, LNCC is a registered nurse with an active license in Arizona. After earning an associate degree in nursing, she started her career in a surgical ICU and was hooked on critical care nursing. While working in several critical care settings, she earned a BSN and an MSN and became certified as a critical care nurse (CCRN). She also discovered nursing within the Veterans Affairs Healthcare System (VA). After about 22 years in critical care, she switched gears and became a Women Veterans Healthcare Program Manager working to improve equal access to quality healthcare for women veterans in the VA. In 2007, she transitioned from the VA and became a legal nurse consultant for a medical malpractice defense law firm. Once she had studied and accumulated enough hours of experience, she became a legal nurse consultant-certified (LNCC). Jean is an active member of the America Association of Legal Nurse Consultants and the Academy of Forensic Nursing. She is also an associate member of the American Bar Association.

Currently, Jean works as an independent LNCC assisting attorneys in medical malpractice, personal injury, and criminal defense. She can be reached at [email protected] or 602-616-9855.

I. Sources of Medical Records and medical information | 2:00pm – 2:30pm

• Acute Care Hospital
• Physician’s office
• Urgent Care
• Free-Standing Emergency Department
• EMS Reports
• Skilled Nursing Facility
• Assisted Living Facility
• Group Home
• Outpatient Care Clinic
• Outpatient Imaging
• Pharmacy
• Physical Therapy Facility
• Chiropractor
• Mental Health Counselor
• Alternative Medicine
• Dietician
• Home Care
• Hospice
• Rehabilitation Facility – Residential and Outpatient
• Employee Health
• Correctional Health Records
• Police Reports – motor vehicle crash
• Video and Audio Recording

II. Obtaining Medical Records | 2:30pm – 2:45pm

• From client
• ROI
• Subpoena
• RFP

III. Medical Record File Management | 2:45pm – 3:00pm

• Tracking Form
• Filing/Naming conventions
  • Plaintiff
  • Defendant
  • Experts
• Medical Record Organization
  • Acute Care Hospitalizations
  • Long Term Care – Skilled Nursing Facility
  • Rehabilitation Facility
  • Outpatient Care
    1. Physician Office
    2. Physical Therapy
    3. Occupational Therapy
    4. Speech Therapy
    5. Urgent Care
    6. Mental Health Provider

Break | 3:00pm – 3:10pm

IV. Medical Record Analysis | 3:10pm -3:40pm

• Medical Chronology
• Identification of missing records
• Summary Medical Records/Factual Basis
• Cast of Characters/List of Medical Providers
• Opinion
  • Review for Merit
  • Is this case defensible
• Identify potential witnesses
  • Experts
  • Lay Witnesses
  • Fact Witnesses
    1. Rule 1006
    2. Rule 30(b)(6) – Arizona Rule
• Medical Literature Research/Review/Analysis

V. Beyond the Medical Record: Other Sources of Evidence | 3:40pm – 4:10pm

• Federal and State healthcare regulations
• Policies and Procedures
• Medical Staff Bylaws
• Credentialing requirements/records
• Employment and academic Records
• Staffing and acuity records
• Pharmacy records – separate documentation package
• Equipment maintenance records
• Remote documentation, remote monitoring
• Logs
• Intake Forms
• Transfer Records