PA 330 – Medical Records – Unit 1

The Body Structure and Function

This Week's Seminar Agenda

Personal Introductions

Comprehensive Overview of This Course

In-Depth Review of Unit 1: The Body Structure and Function

Personal Introductions

Throughout this course, many Discussion opportunities come up where you need to respond to other people's opinions and comments. I'm interested to know what computer hardware and software you're using right now.

Tell us who you are, where do you live, hobbies, interests.

What are your career goals?

What are your expectations for this course?

What do you find most interesting about a Medical Records class?

Summary of Unit 1

This Unit provides an introduction to basic medical terminology that a legal professional will need in order to read and interpret medical records. The two chapters that make up this Unit focus on the systems and the body parts of those systems.

Chapter 3 begins with an introduction to body orientation used in the medical field, including body planes and anatomical positions and directions.

Chapter 4 is an overview of medical diagnostic testing, such as blood and body fluid tests; radiological procedures; physical examination and testing; and motor and sensory function tests including reflexes and mental status. The unit also provides an overview of the components of a medical record.

This week's graded events: Quiz, Discussion, Seminar

Medical Records Case Scenario (1)

Throughout our work together, we're going to focus on a hypothetical fact pattern and the associated medical records. Document Sharing has all the records and reports in PDF format.

How to think like a litigator: Everybody is a potential defendant; the plaintiff must have one or more theories of liability against each defendant; the plaintiff mush have one or more prayers for relief against each defendant; the defendants may have defenses to elements of the theory of liability as well as defenses to remedies.

Every theory of liability breaks down into elements – and that's how the case management software helps both sides organize their thoughts, as well as the evidence.

Medical Records Case Scenario (2)

We're going to be using the Medical Records Case Scenario more during the second half of our work together. Here are the relevant assignments:

Unit 3 (70 points) – Investigation Plan

Unit 6 (70 points) – Request Letter (for documents)

Unit 7 (80 points) – Medical Record Summary

Unit 8 (80 points) – Demand Letter (for damages)

Unit 9 (270 points) – Memo to Attorney (format directions: U9 home page)

Summary of Unit #2

In this unit, we will continue to learn more medical vocabulary. Chapter 5 addresses basic pharmacology, different types of injuries, and related therapeutic treatments. We will also cover the drug approval process by the FDA and various methods to reduce medication error.

This week, we cover pharmacological terms, various types of injuries, and related therapeutic treatments. The pharmacological topics we discuss will include prescriptions with abbreviations, drug administration, drug profiles and drug schedules, and an explanation of the actions, indications, and side effects of several drugs.

This week's graded events: Quiz, Discussion, Seminar

Summary of Unit #3In this unit, you will explore how the legal concept of confidentiality applies to medical records, as well as relevant exceptions that may exist. The unit also discusses the physician-patient privilege and exceptions to that privilege. The topics of peer review and quality assurance will also be discussed. You will write Short Paper #1 this week – Investigation Plan

This week, we delve into the controversial topics of physician-patient privilege and the confidentiality of patient medical records. The doctor-patient privilege is a long recognized doctrine. However, some states have not statutorily recognized this evidentiary privilege. There are certain exceptions to this rule: disclosures made outside the doctor-client relationship; public interest; disclosure of HIV-related information; physician’s duty to warn; workplace safety; workers’ compensation; and third-party payers.

This week's graded events: Investigation Plan Paper, Discussion, Seminar

Summary of Unit #4This Unit will provide you with a working knowledge of the different types of medical records that should be obtained for litigation purposes, as well as the methods for obtaining such records. There are three general types of medical records: pre-hospital care, hospital records, and treating physicians and specialists. Depending on the types of records being sought, both informal and formal methods can be used to acquire the appropriate records. We will also explore when an individual is entitled to obtain his or her own records, as well as third party access to medical records.

Different types of medical records can be obtained for litigation purposes. Three general types of medical records include: pre-hospital care, hospital records, and treating physicians and specialists. This week, we discuss the methods for obtaining such records. Depending on the types of records being sought, both informal and formal methods can be used to acquire the appropriate records.

This week's graded events: Discussion, Seminar.

Summary of Unit #5

Reading Week (Also Catching Up)

Summary of Unit #6This Unit will discuss the many issues surrounding medical records, including who is the “owner” of the records, how long they must be maintained, and the purpose of keeping medical records. This unit also includes information on Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation and how to distinguish spoliation within the medical records.

During this Unit, you will complete and submit Short Paper #2, for which you will prepare information for obtaining medical records of the plaintiff in the Medical Case Scenario.

Some of the many critical issues surrounding medical records include who is the “owner” of the records, how long they must be maintained, and the purpose of keeping medical records. This week, we discuss the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation and spoliation within the medical record.

This week's graded events: Short Paper #2, Discussion, Seminar

Summary of Unit #7This Unit will discuss the importance of summaries for medical records and expenses and various methods for creating medical summaries. We will also explore techniques for interpreting illegible records. In addition, medical research will be addressed and explored. During this Unit, you will prepare Short Paper #3, which is a long-form summary.

Medical record summaries are the key element of the paralegal’s process of organizing the information in a clean, concise manner. The medical summary should include some basic details, including a subjective description of the incident, subjective description of the client's current condition, the medical provider's visual assessment, the client's medical history, a list of the client's current medical complaints, a physical examination report, a statement of the provider's diagnostic conclusion, the client's treatment plan, and a statement of the provider's prognosis for the client.

This week's graded events: Short Paper #3, Discussion, Seminar

Summary of Unit #8This unit will discuss the role of the medical consultant in evaluating the medical record, as well as certain evidentiary requirements for use of a consult. We will also explore issues regarding evidentiary requirements for using expert witnesses at trial, examine national and local rules related to experts and their reports, and locate experts in your state.

The consultant's role is rather broad and aids the attorney throughout the legal process. Through the textbook readings, we discuss the role of the medical consultant as well the role of the expert witness. The scope of the expert witness is less broad than the consultant's. The expert witness generally only provides testimony within his or her specific field of expertise. The Federal Rules of Evidence and each state address the issue of who may be considered an expert witness before the person's testimony is admissible in court. During this Unit, you will draft Short Paper #4, which is a demand letter used during the settlement process.

This week's graded events: Short Paper #4, Discussion, Seminar

Summary of Unit #9In this unit, we will discuss the concept of hearsay and how it relates to the introduction of medical records into evidence at trial. We will also explore various types of demonstrative evidence -- what types are available and how these assist the trier of fact in a greater understanding of the issues involved in a case. Finally, this Unit will cover the admissibility issues surrounding duplicated medical records. You will prepare your Final Project during this Unit, which will be a legal memorandum to a supervising attorney.

In this unit, we discuss how the Trial Book and the Evidence Book are tools attorneys use when preparing for trial. This week’s textbook reading includes a brief description of each section that the books might contain. One of the most important points of this chapter is that the medical record is considered hearsay. It must be shown that the medical record falls under one of the exceptions to the hearsay rule before the record will be admissible in court. Also, state requirements must be met before a duplicate of the medical record is considered admissible.

This week's graded events: Final Exam, Project, Discussion, Seminar

Summary of Unit #10

Reflection, Review, Catching Up

Unit 1: Body Structure & Function (part 1)

Chapter 3 begins with an introduction to body orientation used in the medical field, including body planes and anatomical positions and directions.

A general overview of major body systems follows, including the cardiovascular, respiratory, digestive, skeletal, muscular, nervous, urinary, endocrine, blood and immune, integumentary, and reproductive systems. General anatomical diagrams are provided.

Let's look at some of the key terms:

Unit 1: Body Structure & Function (part 2)

Body Planes:

• Median Plane

• Coronal/Frontal Plane

• Transverse/Cross-horizontal Plane

Body Movements:

• Extension

• Flexion

• Abduction

• Adduction

Unit 1: Body Structure & Function (part 3)

Body Structures

Body Systems

Respiratory, Digestive, Skeletal, Muscular, Nervous, Urinary, Endocrine, Blood and Immune, and Intergumentary Systems

Unit 1: Body Structure & Function (part 4)

Chapter 4 is an overview of medical diagnostic testing.

Areas covered include:

blood and body fluid tests; radiological procedures; physical examination and testing; motor and sensory function tests including reflexes and mental status; newborn assessment; and several types of diagnostic tests performed during pregnancy including ultrasound, amniotic fluid volume tests, stress testing, and electronic fetal monitoring.

Again, a great deal of terminology is associated with this chapter.

Unit 1: Body Structure & Function (part 5)

Diagnostic Radiology

Physical Examination and Testing

Motor and Sensory Function Test

Mental Status

Diagnostic Testing During Pregnancy

This Week's Discussions#1: The Medical Record's Role in a Medical Malpractice Case

Read "Medical Record Documentation - Is Yours a Help or a Hindrance in a Lawsuit?" With your classmates, discuss how the medical record plays a pivotal role in a medical malpractice case.

Please post your responses on the Discussion Board.

#2: What Do You Think about Electronic Medical Records?

Based upon your research, discuss your opinion on electronic medical records. Are you pro or con? Why? Be sure to reference the Internet sites you visited.

Please post your response on the Discussion Board.

Preview of Unit 1 Quiz

30 Minutes

Ten Questions: 8 multiple choice, 2 true/false

Medical Terminology is on the Agenda.

30 points are at stake.

This Week's To-Do List

Seminar – or Alternate Assignment

Discussion Board

Quiz

Good Evening!

I'm looking forward to 'seeing' everybody again next week!

Unit 2: Therapeutic Treatment Modalities