What we do.
Conduct a thorough review and document all relevant findings
Create a timeline of events
Write an elaborate report noting any discrepancies
Identify missing/incomplete records
Medical Records
Emergency Department
Urgent Care
Inpatient/outpatient Hospitalizations
Outpatient Clinics
Medication Management
Pain Management
Behavioral Health
Laboratory
Genetic testing
Surgical procedures/interventions
Long Term Living Facilities
Home Health Care
Records reviewed:
Physician notes
Nursing notes
Specialist consultations
Outpatient consultations
Wound care
Skin breakdown
Failure to Thrive
Medical neglect
Autopsy photos/reports
Patient billing
Standard of Care
During the documentation and extraction of material medical events, special notation will be made in scenarios where there is a deviation from the Standard of care for nurses and/or caregivers.
Indicators
Documenting and analyzing trends in vital signs, weight checks, existing medication, deterioration in health condition, change in behavior such as; inappropriate displays of affection in relation to a person's age and/or relationship to caregiver.
Acquired Conditions
Common environmentally acquired infections and/or additional conditions secondary to injury. Hospital acquired infections/conditions (MRSA, aspiration pneumonia).
Juvenile Dependency
Conduct a thorough review and document findings pertinent to the specific case. Incorporate petitions, social studies, delivered service logs and Health Education Passports. Documentation of supervised visits and visitation log.
Records:
Detention report
Jurisdiction report
Disposition report
Adjudication report
Delivered Service Logs
Court orders
BYPASS provisions
TPR - Termination of Parental Rights
Adoption
Foster Care
Guardianship
Foster Care Rates
SIR - Special Incident Reports
Special Focus on; Social workers recommendations to the court, bonding evaluations, consistency of social workers visits with minor, reports of abuse/neglect of child in out of home care, medical forensic exams, court ordered services, reviewing accuracy of reports submitted to the juvenile court based on documentation in case file.
