Key Document Management System Features

R&G LCMS

The paperless office is here to stay, with many businesses, large and small, making the move to online storage. Document management systems come in various forms. Some are simple online filing systems, others are complex with features such as access control, audit trails, encryption, and data backup. The type of information a business maintains is a driver for the type of security needed as a safeguard. For example, law firms often need a system associated with case files that safeguard client personal health care information. A small business many need a billing document management system.  

A robust document management system should offer multiple layers of protection. For example, access controls allow individuals permission to access data. Two examples are personal identification numbers and passwords. Some passwords are specialized and require special characters. The more complex the password, the less likely a hack will occur. Audit trails are another means of protection which provide a history of who viewed certain data and when. It allows for the tracking of a source of a breach. Lastly, encryption provides a way to share files securely as well as limits the viewing of certain documents.  

A good document management system also has a data backup feature. This occurs when data is replicated to an additional system such as the cloud. Theft, data loss, or a natural disaster are just a few reasons to incorporate redundancy into the system as data redundancy is essential for speedy and seamless recovery. If there is no built-in redundancy, the opportunity for recovery of files may be forever lost. The key to redundancy is to balance the redundancy so that data remains as clean and up to date as possible.  

Document collaboration is a more sophisticated feature of an online system. This feature allows for mark up, versioning, searchability, e-signature and customized security. While overkill for some businesses, the features are essential for others.  

Customer support is essential for any document management system. A standard method for contacting the developer should be known and responses should come quickly when there are questions. A client portal with a help button is a common feature for many systems.  

R&G offers clients a Legal Case Tracking System as a secure means of online case storage information. The Legal Case Management System (LCMS) is an integral part of workflow management at R&G. LCMS is a state-of-the-art database providing anytime-anywhere access to case details, retrieved medical records, and completed work products. 

There are no additional fees associated with access. All of R&G’s medical legal consulting or document management clients can: 

  • Track case deadlines and status of records in real time 
  • Access medical records and completed work products 
  • Data is safe and private! LCMS uses BOTH redundant storage (to protect your data in real-time) AND frequent backups (to protect data in case of disaster) 

If you need assistance with a case, please call R&G Medical Legal Solutions at 1-888-486-2245. 

Medical Abbreviations

The use of medical abbreviations has been used since the development of medicine and is a longstanding practice. They are thought to save time and space when writing medical records. Additionally, they are cost effective and can be customized. While many healthcare facilities have gone to electronic records, the practice of handwritten records still exists, thus the continuance of handwritten medical abbreviations.  

Paper records are prone to errors. Illegible writing causes confusion and at times, a delay in care due to a need for follow up with the author for clarification; especially when it comes to medication orders and dispensing. Many abbreviations may have more than one meaning and the staff interpreting the record may not be familiar with the abbreviation being used.  

In 2005 The Joint Commission, an enterprise that accredits and certifies healthcare organizations, adopted a list that is forbidden to be used by Joint Commission accredited facilities. Below is the list along with an explanation of the potential problem.  

*DO NOT USE POTENTIAL PROBLEM USE INSTEAD  
U, u Mistaken for “0” (zero), the number “4” (four) or cc Write “unit” 
IU (international unit) Mistaken for IV (intravenous) or the number ten (10) Write “International Unit” 
Q.D., QD, q.d., qd (daily)   Mistaken for each other  Write ‘daily” 
Q.O. D., QOD, q.o.d., qod Period after the Q mistaken for “I” and the “O” mistaken for “I” Write “every other day” 
Trailing zero (X.o mg) (Applies to medication orders) Decimal point is missed  Write X mg Write 0.X mg 
MS     MSO4 and MgSo4 Can mean Morphine Sulfate or Magnesium Sulfate   Confused for one another  Write “morphine sulfate” Write “magnesium sulfate” 

 2020 The Joint Commission Fact Sheet 

*List does not apply to preprogrammed health information technology systems.  

The Joint Commission has made a recommendation to not sure the symbols for “greater than” or “less than” as they may be interpreted for the letter L or the number 7. The symbol for at (@) is discouraged because it may be misinterpreted as the number 2. Instead, providers should write out the words, “greater than”, “less than” or “at” as they appropriately apply in the chart.  

Misinterpretation of abbreviations may result in patient harm to include death. R&G nurses are skilled at reading handwritten records and recognized when a contributing error has occurred. If you are an attorney and need help with your case, please contact R&G at 1-888-486-2245. 

R&G LNC Services

Legal Nurse Consultant -AALNC

R&G provides services to firms of all sizes.  Services are performed by US-based registered nurses who possess both clinical nursing experience and specialized legal training. Effective partnerships between R&G and clients are facilitated through the use of Project Managers who ensure timely delivery of work products. 

Though not required, clients and Project Managers use R&G’s proprietary, secure, legal case management system with a built in DICOM viewer, to monitor project progress in real time, with the ability to access finished work products, anytime, anywhere.  All work products are customizable to meet the needs of the clients.

We use US-based Legal Nurse Analysts working in a secure virtual environment. We also offer our clients Virtual Legal Nurse Associates. R&G will match a highly experienced and appropriately specialized LNC to your case.  The nurse can work either on a short term or long term basis.  Client’s have direct access to their assigned nurse in order to facilitate communication.

Give us a call today to discuss your case needs!

Phone: 1-888-486-2245

Email: rngrfp@rngmedical.com

Your Trusted Legal Solutions, On Time, On Target, On Task