A medical record is a powerful tool that enables the care and treatment provided to patients by all healthcare professionals to be chronologically tracked.  It contains the patient’s medical history, diagnostic testing and assessment notes from various medical disciplines.  It helps identify problems or patterns and assists in determining the best course of medical management for a patient.

Registered Nurses are diverse in their knowledge and experience.  They review, analyze and interpret a large and varied amount of medical documentation daily.  Nurses understand the medical terminology of physicians and other healthcare providers.  Nurses are the healthcare providers that are caring for and assessing patients for the greatest number of hours in a day and their documentation makes up a large portion of a patient’s medical record in the clinical setting.

At Wendy Peters Medical Legal Nurse Consulting & Health Record Review Services, we provide confidential, efficient and timely review of health records without bias.

“You must be the change you wish to see in the world.”
– Mahatma Gandhi         

 


Reviewing and analyzing health records. To determining if standards of nursing care & practice have been met. Compiling medical information for statistical or research purposes.

interpreting_medical_recordsDeveloping chronological timelines with health records.

law gavel-230x230Comprehensive written reports for evidence in legal cases. Review of  health documentation to determine eligibility for medical insurance claims.