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.
Wendy Peters Legal Nursing Consulting & Medical File Review Services strives to improve, support and uphold the standards of nursing care through education, research, quality assurance and consultation. Providing confidential, accurate and timely review of each medical file without bias.
“You must be the change you wish to see in the world.”
– Mahatma Gandhi