The
'recommended only' readings for this unit are the following:
Australia |
Recommended
Reading(s)
|
 |
Insert article/book/chapter
here
Canada |
Recommended
Reading(s)
|
|
McGregor,
M. J., Le, G., Marion, S. A., & Wiebe, E. (1999).
Examination for sexual assault: Is the documentation
of physical injury associated with the laying of charges?
A retrospective cohort study. Canadian Medical Association
Journal, 160(11), 1565-1574.
- The
study was a retrospective cohort analysis of all
cases of sexual assault seen in 1992 by the BC Women's
Sexual Assault Service for which there was police
involvement and for which a medicolegal report and
information about the legal outcome were available.
|
International |
Recommended
Reading(s)
|
|
Insert article/book/chapter
here
United Kingdom |
Recommended
Reading(s)
|
|
Grange, A., Renvoize,
E., & Pinder, J. (1998). Patient's rights to access
their health care records. Nursing Standard, 13 (6),
41-42.
- Note the
compelling reasons for making records more accessible
to patients and the potential benefits for patients and
professionals.
Slaney, M. &
Vaughan, P.J. (1998). Patient access to psychiatric assessment
reports. Psychiatric Care, 5 (6), 225-227.
- Note in keeping
with increased openness of information this study reports
on results of offering psychiatric patients copies of
their assessment reports.
Yates, M. &
Deakes, C. (1998). Introducing multidisciplinary record
keeping in a forensic setting, Psychiatric Care, 5 (6),
204-207.
- Note this
audit study of medical records and the recommendations
for patient participation and joint multidisciplinary
record keeping.
United States |
Recommended
Reading(s)
|
|
Cochran, M. (1999).
The real meaning of patient-nurse confidentiality. Critical
Care Nursing Quarterly, 22 (1), 42-51.
- Note the
importance of confidentiality of medical records.
Epstein, L.
M. (1996). A case study: Medical records evidence and expert
testimony by a LNC in a criminal case. Journal of Legal
Nurse Consulting, 7(4), 7-9.
- Note the
responsibilities of the legal nurse consultant as expert
witness when medical records are presented as evidence.
Goll-McGee,
B. (1999). The role of the clinical care nurse in critical
care. Critical Care Nursing Quarterly, 22 (1), 8-18.
- Note the
protection that scrupulous documentation provides.
Hanzlick, R.
L. (2000). The autopsy lexicon: Suggested headings for the
autopsy report. Archives of Pathology & Laboratory
Medicine, 124(4), 594-603. Retrieved December 24, 2002,
from
ProQuest database.
- Although standard
autopsy texts and other publications discuss the general
content of autopsy reports, and some provide examples
of autopsy report formats, na publication to date has
recommended specific headings for autopsy report organization.
The College of American Pathologists Autopsy Committee
decided if would be helpful to provide suggestions for
autopsy report headings to foster more standardized autopsy
reporting, to facilitate review of reports by third parties,
and to facilitate searches of electronically stored autopsy
reports. Objectives.-To create a model document (named
the Autopsy Lexicon), which defines standard categories
of information that are useful to include in autopsy reports;
to offer specific wording for the headings of various
sections of the report; and to explain the rationale for
including the various items of information and headings.
Participants and Methods.-The members of the Autopsy Committee
of the College of American Pathologists prepared the document
by reviewing various examples of autopsy ….
Lamb, D. L. (1997).
Confidentiality of medical records, Part II: Electronic
patient records. Journal of Legal Nurse Consulting, 8
(4), 16-17.
- Note, as
we become more accustomed to using computerized informational
systems, we will need to become more adept at protecting
the sensitive information contained within them (Lamb,
1997, p. 16).
Loecker, B.L.
(1998). Attorney-Client Privilege and confidentiality. Journal
of Legal Nurse Consulting, 9 (1), 14-15.
- Note the
references to privileged communication ad confidentiality.
Pasqualone,
G. A. (1996). Forensic RN's as photographers: Documentation
in the ED. Journal of Psychosocial Nursing and Mental
Health Services, 34, (10), 47-51.
- Note the
important role of photography as a documentary tool.
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Topic
C - Forensic Nursing > Section C.4.0. Forensic Practice/Prevention
> Unit.C.4.4. Documentation/Medical Records/Confidentiality
