Are you prepared?

You never know what tomorrow will bring. Anyone’s personal health history can change at any given time, but as we get older or our loved ones get older, the chance of this happening becomes more significant. Statistics from the National Council on Aging tell us, 92% of all retired age people will, at some point, have at least one chronic disease, and 77% will have at least two.  

If you can lessen the load for your loved ones down the road, wouldn’t you be willing to get their medical records organized, so you have the critical information at your fingertips when there is a medical crisis. R&G Medical Legal Solutions has developed a factual, chronological medical history customized for you or your loved one.  

Some items for consideration: 

  • If your loved one was incapacitated today – would you know what medications they take, the dose and when they started taking it, and why they are taking the medicines?  
  • Are you overwhelmed with multiple records filled with treatments or procedures? 
  • Can you or your loved one access or navigate their doctor portals? 
  • Would you know what allergies a new doctor should be aware of to minimize any complications or interactions?  
  • When was their last surgery? 
  • If you have this information, is it current?  
  • Is the information somewhere secure and available to you when you need it most?  

R&G Medical Legal Solutions has developed an innovative Personal Medical Profile with one basic idea in mind: a vital document for continuity of care or medical crisis. Don’t leave your caregiver or loved ones guessing.   

Our Personal Medical Profile is an easy-to-read, factual document for you to access or share with your physicians, healthcare proxy, or family members of your choice. All vital information will be outlined on the first page, followed by individual doctors’ visits, facilities, or hospital admissions. Our Personal Medical Profile has a minimal fee to get started, and all plans are subscription-based depending on the level of care your loved one receives. We will update the profile when you notify us of a new medical visit or admission. You will always be up to date to be the best advocate for your loved one. 

Whether you work with us or not, we encourage you to have this vital document. Please click here if you would like more information on the Personal Medical Profile from R&G Medical Legal Solutions. 

Coordinating Care for a Loved One from Afar

Being involved in the care of a loved one can be both rewarding and joyful. Providing love, physical and emotional support along with companionship is a noble thing to do. Some acts of caregiving are easier than others. Coordination of medical care is one of the more challenging tasks. Many caregivers find this aspect time-consuming and frustrating. For example, managing medication refills, follow-up appointments, and post-visit instructions can be overwhelming.

Sometimes a loved one can have difficulty articulating their complex medical history to a new medical team member. The caregiver is often called upon to assist. A chronological document that outlines the loved one’s past medical history can make health appointments much easier in terms of providing medical information efficiently. A computerized document is recommended given the ability to edit /update information. For example, the weight of the loved one may fluctuate. However, not everyone has access to a computer therefore a handwritten history will suffice.

As a layperson knowing what aspect of medical history to document is a challenge. For example, is there a need to document medications the loved one no longer takes? Why are height and weight important? Should every medical appointment be logged are a few questions to consider.

Below is a suggestion of important historical information to consider. If dates of diagnosis are known, include.

·      Name and date of birth

·      Do you know the patient’s height and weight?

·      Do you know important blood relative family health history (any significant medical history such as heart, lung, cancers, mental health disease)?

·      Are you aware of all past surgeries including dates and reasons?

·      Any past hospitalizations? Also to include reasons and dates.

·      Any chronic and ongoing medical history to include cancer, heart disease, diabetes, high blood pressure, high cholesterol, kidney disease, chronic

pain?

·      What are the current medications and dosages? Include medications recently stopped taking, including supplements and over the counter.

Information contained in the document is meant to be helpful to a medical team member, if there is other information the caregiver believes is important and significant, it should be included.

In sum, a well-written document containing significant medical history can assist a care provider working with the loved one’s medical team. The document is meant to be flexible in that information may be added or sometimes even removed. The document should be taken to each health care appointment.

R&G Medical Legal Solutions, LLC is rolling out a new program related to providing clients with a “Personal Medical Profile”. Please visit our website at www.rngmedcons.com/pmp for more information.

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. 

How Veteran Nurses Help Distinguish R&G

Service Disabled Veteran Owned Small Business

January 2021 

Beth Ann Lumpkin, Lt. Col., USAF, NC (Ret.)

Thousands of registered nurses served as active duty, guard or reserve member in the Army, Air Force and Navy Nurse Corps, even the Public Health Service. Individual service duration varied anywhere between three to twenty years.  

The skills acquired in the military are extremely valuable for the civilian job market. Leading teams, critical thinking, cultural sensitivity, organization, adaptability, attention to detail, varied work hours, and solid work ethic are just a few of the traits Veteran nurses gained while on military duty. These traits make military nurses well suited for legal nurse consulting work.  

Nurses with a military background are highly educated. The structure of the military provided professional military education with each level of rank and nursing specialty. Veteran nurses have a variety of specialties translatable to nurse consulting. For example, specialties include operating room, infection control, quality assurance, midwifery, mental health, aeromedical evacuation, critical care and medical surgical are just a few of the areas for which military nurses have provided care. Military nurses provide care in both the inpatient and outpatient settings, and military nurses are trained in managing acute trauma under battlefield conditions. Military nurses must complete continuing education on an annual basis unlike some requirements from states for civilian nurses.  

R & G is a veteran owned and established business that works with a variety of clients. Highly experience nurse consultants, to include some military nurses, are part of the equation that allows R&G to provide outstanding service.  

Please give us a call today to see how legal nurse consulting at R&G can solve problems for you and/or your firm.  Dial 1-623-566-3333 today.  

Legal Nurse Consultants… Put them into action

A legal nurse consultant (LNC) is a subject matter authority on nursing and healthcare matters much like how an attorney is an expert in legal matters. They are state licensed, detail-oriented healthcare professionals, working on behalf of the litigation team.  

Legal nurse consultants apply their knowledge, education, and clinical training to medical legal cases. Supreme is their ability to interpret medical records. Using their nursing knowledge, LNCs can quickly evaluate medical records and distill them into comprehensive summaries, or chronologies. Their attorney clients can then quickly read, understand, and put them into action. 

The primary role of LNCs involves the identifying, analyzing, and evaluating medical records while providing their professional opinions regarding health issues in medical legal cases. This field of study is composed of evaluating the standards of care, causality, and other medically related issues through the examination of medical records, healthcare literature, and legal documents. Their expertise extends to multiple topics, including: long-term care, medical malpractice, personal injury, worker’s compensation, and mass-tort litigation.  

Legal nurse consultants will also be able to establish a chronology or summary of medical records, and prepare evidence for trial. Additionally, they act as a liaison between the attorney, the healthcare provider, and medical experts. In brief, legal nurse consultation is a valuable asset to the litigation team. 

R&G Medical Legal Solutions has an extensive team of certified legal nurse consultants, that are available around-the-clock, 24-7, to assist you with anything you need. We are agile, in that we can scale up or scale down the project workload to adapt to your needs as they change. Please give us a call today to see how legal nurse consulting at R&G can solve problems for you, dial 1-623-566-3333 or send us an email: rngrfp@rngmedical.com