Governing principles: effective use of medical evidence

• Author: R. John Naranja
• Pages: 649-690

PART III

LITIGATION TOOLS

(Τηισ παγε ιντεντιοναλλψ λεφτ βλανκ.)

GOVERNING PRINCIPLES:

EFFECTIVE USE OF

MEDICAL EVIDENCE

22-1

CHAPTER 22

GOVERNING PRINCIPLES:

EFFECTIVE USE OF MEDICAL EVIDENCE

I. ATTORNEY’S GUIDE TO UNDERSTANDING MEDICAL RECORDS

A. Introduction

B. Access to Medical Records

§22-1 HIPAA

§22-2 Ordering Medical Records and Bills

C. Types of Medical Providers

§22-3 Ambulance Personnel

§22-4 Emergency Room Doctor (MD or DO)

§22-5 Primary Care Provider

§22-6 Specialty Care Providers

§22-7 Chiropractors, Physical Therapists, Massage Therapists

§22-8 Mental Health Care Providers

§22-9 [Reserved]

D. Organization of Medical Documents

§22-10 Physician Charts

§22-10.1 Chief Complaint (CC)

§22-10.2 History of Present Illness (HPI)

§22-10.3 Review of Systems (ROS)

§22-10.4 Past Medical History (PMH)

§22-10.5 Family History

§22-10.6 Social History

§22-10.7 Medications

§22-10.8 Physical Examination (PE)

§22-10.8.1 Observation or Inspection

§22-10.8.2 Palpation

§22-10.8.3 Range of motion

§22-10.8.4 Neuro testing

§22-10.9 Laboratory Data/Imaging

§22-10.10 Assessment/Diagnoses

§22-10.11 Plan/Medical Decisionmaking

§22-11 Operative Reports

§22-12 Radiology Reports

§22-13 Pathology Report

§22-14 Chiropractic and Physical Therapy Records

[Editor’s Note: All medical illustrations that appear or are referenced in this chapter are available online – in full-size

and most in four-color – through James Publishing Digital Access.]