Medical Records can be daunting for any criminal attorney or investigator to review. The purpose of the presentation is to assist attorneys in focusing their review of medical records and to focus on review of records that contain the information that both civil and criminal attorneys are commonly seeking. To make it relevant and interesting, the records included in this presentation follow an attempted murder case and highlight not only what is in the records but also what might be missing.
This course is co-sponsored with myLawCLE.
Key topics to be discussed:
Recognize where to find pertinent case information within the medical records
Determine when medications were administered and where to look for medication errors
Recognize red flags for medical errors in operative reports
Understand different modes of medical transport and levels of care provided
Identify documents and who is responsible for the information within
Date: November 18, 2022
Tara Godoy, BSN RN CFN | Godoy Medical Forensics
Tara Godoy is a Certified Forensic Nurse and has been working with Criminal and Civil Attorneys for over 10 years. She has a BS in Nursing from the University of Southern California and currently lives in the San Francisco Bay Area. Through consulting and testimony, she has assisted both the prosecution and the defense in obtaining an honest and fair resolution in hundreds of criminal cases.
Along with her nursing staff and physician contractors, Godoy Medical Forensics has consulted on over 1500 cases nationwide and has worked at both the federal and state levels. Tara has been asked to present for national organizations such as the NACDL and the NDIA at their Forensics conferences in Las Vegas. Tara’s main areas of expertise are Strangulation and Blunt Force Trauma, but testimony is also offered on other cases where traumatic injuries occur, or medical record analysis is needed. Tara can be reached at [email protected].
I. Introduction | 2:00pm – 2:10pm
II. Discharge Summary, H&P, Consults | 2:10pm – 2:20pm
Review of records that summarize the patient’s care while in the hospital
Distinguishing between narrative reports
III. Emergency Department Reports | 2:20pm – 2:30pm
Review of the types of records and where to find critical information
Brief review of labs
IV. Transport Records | 2:30pm – 2:40pm
How to tell the difference between Pre-hospital (911 providers) and Interfacility transports and levels of care provided
What information can be critical to your case
V. Surgery and Radiology | 2:40pm – 2:50pm
How to read operative reports
Where to find the information you need on XRay and CT Scan reports
VI. Medications and Orders | 2:50pm – 3:00pm
When is a drug actually given and why orders can be confusing