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).

Medical Malpractice

Intricate review of any/all hospitalizations/urgent care records
Establish baseline through review of family history, historian/collateral interviews
Incorporate expert reports, noting cases of “running diagnoses”
Produce chronology of laboratory studies, vital signs, medication management, radiology examinations, specimens sent to outside facilities
Identify missing records, specialty consultations and consent forms
Note changes in condition in accordance with administered procedures/treatments
Production of multi-event timeline from the time of admission to discharge
Identify any supplemental therapy (PT/OT/ST)
Note change in condition; when, why, who (Date of occurrence, as a result of, performed by X)
Produce list of all providers involved a patient’s treatment; residents, nurses, therapists, specialists, hospitalists, social workers

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 worker's recommendations to the court, bonding evaluations, consistency of social worker's 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.