TY - BOOK AU - Quinn,Campion TI - The medical record as a forensic resource SN - 0763727598 (pbk.) PY - 2005/// CY - Sudbury, Mass. PB - Jones and Bartlett KW - Forms and Records Control KW - methods KW - Medical Records KW - legislation & jurisprudence KW - Forensic Medicine N1 - What is the medical chart? -- Acquiring the medical chart / Karen Fielder -- Authorization for release of medical information -- Determining what is missing from the medical chart -- How to examine an individual medical chart -- Face sheet -- Consent forms -- Living will/power of attorney -- Preadmission records -- Ambulance call report -- Emergency department record -- Admission note -- Physician order sheet -- Progress note -- Consultation note -- Anesthesia note -- Procedure note -- Discharge summary -- Radiology report -- Laboratory and pathology reports -- Autopsy report -- Nursing notes -- Medical policies -- Incident reports -- Medication errors / Kim Zammit -- The medical chart as evidence / Edward Birnbaum and Carl Grasso -- Tampering or falsification -- Malpractice basics -- Pain and suffering -- Personal injury claims ER -