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1 n s t i t u t e I N Y C L A - C L E A L awyer s G uide to M edical R ecords : U nderstanding the S tory T hey T ell and H ow to U se T hem Prepared in connection with a Continuing Legal Education course presented at New York County Lawyers Association, 14 Vesey Street, New York, NY presented on Wednesday, February 13, P r o g r a m F ac u l t y : Monica Merrill, Kelner and Kelner Jonathan Weinstein, M.D., Esq., Voute, Lohrfink, Magro & McAndrew, LLP 2.5 TRANSITIONAL & NON-TRANSITIONAL MCLE CREDITS: This course has been approved in accordance with the requirements of the New York State Continuing Legal Education Board for a maximum of 2.5 Transitional & Non-Transitional credit hours: 1 Skills; 1.5 PP This program has been approved by the Board of Continuing Legal Education of the Supreme Court of New Jersey for 2.5 hours of total CLE credit. Of these, 0 qualify as hours of credit for Ethics/Professionalism, and 0 qualify as hours of credit toward certification in civil trial law, criminal trial law, workers compensation law and/or matrimonial law.

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3 Information Regarding CLE Credits and Certification Property Insurance for Apartment Buildings: Learning From Sandy Wednesday, February ; 9:00 AM to 12:00 PM The New York State CLE Board Regulations require all accredited CLE providers to provide documentation that CLE course attendees are, in fact, present during the course. Please review the following NYCLA rules for MCLE credit allocation and certificate distribution. i. You must sign-in and note the time of arrival to receive your course materials and receive MCLE credit. The time will be verified by the Program Assistant. ii. iii. iv. You will receive your MCLE certificate as you exit the room at the end of the course. The certificates will bear your name and will be arranged in alphabetical order on the tables directly outside the auditorium. If you arrive after the course has begun, you must sign-in and note the time of your arrival. The time will be verified by the Program Assistant. If it has been determined that you will still receive educational value by attending a portion of the program, you will receive a pro-rated CLE certificate. Please note: We can only certify MCLE credit for the actual time you are in attendance. If you leave before the end of the course, you must sign-out and enter the time you are leaving. The time will be verified by the Program Assistant. Again, if it has been determined that you received educational value from attending a portion of the program, your CLE credits will be pro-rated and the certificate will be mailed to you within one week. v. If you leave early and do not sign out, we will assume that you left at the midpoint of the course. If it has been determined that you received educational value from the portion of the program you attended, we will pro-rate the credits accordingly, unless you can provide verification of course completion. Your certificate will be mailed to you within one week. Thank you for choosing NYCLA as your CLE provider!

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5 New York County Lawyers Association Continuing Legal Education Institute 14 Vesey Street, New York, N.Y (212) A Lawyer s Guide to Medical Records: Understanding the Story They Tell Wednesday, February 13, 2013 Faculty: Monica Merrill, Kelner and Kelner; Jonathan Weinstein, M.D., Esq., Voute, Lohrfink, Magro & McAndrew, LLP 5:30 PM 6:00 PM Registration AGENDA 6:00 PM 6:15 PM Purpose of the Medical Record: Understanding the Why and How of the Plan Understanding How Medical Personnel are Taught to Document 6:15 PM 6:25 PM First Things You Need to Know When Confronted with Medical 6:25 PM 6:45 PM Sections of the Medical Record: Who are the Writers? What do They do and What do They have to Say? Medical Hierarchy and Writers 6:45 PM 7:00 PM Standard Abbreviations to Know for Interpreting a Medical Chart Cross Referencing information for a Timeline 7:00 PM 7: 15 PM Short Cuts You Need to Know 7:15 PM 7:30 PM Medical Documents outside the Patient Chart Autopsy and ME records Photographs and videotape Monitoring strips and data collection, telemetry, fetal monitor strips, intra operative data Committee reports Log Books Pathology Incident Reports Policy and Procedure Manuals Clinical Protocols 7:30 PM 7:45 PM The Medical Record in Varied Legal Settings PI

6 Administrative proceedings ss, disability, workers comp, disciplinary matters Criminal proceedings Family Law Trusts and estates testamentary capacity Psychiatric situations Education Law Civil Rights ADA 7:45 PM 8:00 PM Presentation of Data for Reports, Trial, etc. 8:00 PM 8:15 PM Medical Records and Litigation: Depositions, Evidence 8:15 PM 8:20 PM Electronic Medical Records Solution or Problem 8:20 PM 8:30 PM Questions and Answers

7 New York County Lawyers Association Continuing Legal Education Institute 14 Vesey Street, New York, N.Y (212) A Lawyer s Guide to Medical Records: Understanding the Story They Tell Wednesday, February 13, 2013 Faculty: Monica Merrill, Kelner and Kelner; Jonathan Weinstein, M.D., Esq., Voute, Lohrfink, Magro & McAndrew, LLP Table of Contents The Medical Record: Telling a Story Monica Merrill, Kelner and Kelner Outline NY PBH Law Sec. 17: Release of Medical Records Department of health Memorandum: Access to Patient Information HIPAA Preemption Analysis Summary of the HIPPA Privacy Rule Abbreviations The Medical Records and the Story They Tell: Slides Jonathan Weinstein, M.D., Esq., Voute, Lohrfink, Magro & McAndrew, LLP Faculty Biographies

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77 Medical Records and The Story They Tell Jonathan Weinstein, M.D., J.D. Vouté, Lohrfink, Magro & McAndrew

78 Medical Records & the Story they Tell First Things You Need to Know Example: Hospital admission Face Sheet What is a Face Sheet? Initial informational page in patient s chart Contains all/most of the patient s information vitals Sometimes updated during the admission

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80 Medical Records & the Story they Tell First Things You Need to Know

81 Medical Records & the Story they Tell Medical Hierarchy and the Record Writers Teaching hospital

82 The Teaching Hospital Medical Hierarchy and Record Writers

83 Medical Records & the Story they Tell Medical Hierarchy and the Record Writers Private medical clinic/office Usually records of May have outside records interspersed Usually recorded

84 Medical Records & the Story they Tell Short Cuts You Need to Know Short on time? Go straight to these documents:

85 Medical Records & the Story they Tell Presentation of data Most common presentation: What you may need to do: Consider charts, graphs, etc., if helpful

86 Your thoughts Suggestions for future presentations Any questions? Potential future programs Anatomy for attorneys Basic pharmacology Medical ethics Others? Jonathan Weinstein, M.D., J.D. Vouté, Lohrfink, Magro & McAndrew

87 Faculty Biographies Jonathan I. Weinstein Associate, Vouté, Lohrfink, Magro & McAndrew, LLP (VLMMC) Born New York, New York, May 9, 1967; admitted to New York Bar Education: Cornell University (B.A. 1989), State University of New York School of Medicine (M.D. 1993), New York Law School (J.D. 2011), Member: New York State Bar Association. Monica R. Merrill Monica Risi Merrill has been with Kelner & Kelner since She is the attorney in charge of the Medical Malpractice Department, and has been involved in cases involving all specialty areas of medicine, including internal medicine, surgery, anesthesiology, orthopaedics and maternal and child health. Mrs. Merrill is a registered nurse with clinical experience in critical care and coronary care nursing. Her educational and clinical preparation provide her with a high level of knowledge and expertise in medical malpractice cases. She has been responsible for hundreds of medical malpractice actions brought to successful financial conclusion, dozens of which have resulted in recoveries in excess of two million dollars, including: $2,750,000 for the death of a 17 year old for failure to diagnose brain bleed after childbirth; $3,000,000 for neurologic injury suffered by a young mother of 2 as a result of the failure to diagnose cerebral aneurysm; $3,900,000 for failure of an orthopedist to diagnose spinal cord bleed resulting in paraplegia of a young woman; $4,500,000 for the death of a young mother of 3 as a result of anesthesia mismanagement during a tubal ligation; $5,500,000 for permanent brain damage suffered by a young man as a result of the failure to provide proper respiratory care; $6,000,000 for brain damage suffered by a 17 year old during a gynecologic procedure; $17,000,000 for the wrongful death of a businessman as a result of a delay in intestinal surgery. Mrs. Merrill has extensive expertise in case analysis, evaluation, research, preparation and discovery proceedings. She has taken sworn testimony from hundreds of physicians, nurses and medical workers. She is also experienced in all aspects of complex products liability litigation involving medical devices, equipment and pharmaceutical preparations. Mrs. Merrill has taught and lectured on both the graduate and undergraduate levels in nursing and health law related issues. She has been an a member of the Adjunct Faculty Graduate Division - Hunter-Bellevue School of Nursing; a Lecturer at the Queensborough Community College-Department of Nursing; a Mentor Attorney in the Externship Program of New York Law School and an attorney panelist for the Medical Malpractice Mediation Panel for the First Department, Bronx County. She is a former Board member of the Metropolitan Chapter of the American Association of Nurse Attorneys. Mrs. Merrill is a graduate of Hunter-Bellevue School of Nursing and New York Law School. She is admitted in the New York State Courts, United States Federal Courts of both the Eastern and Southern Districts of New York, the United States Supreme Court and is a member of the New York State Bar Association.

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