Avoiding Potential Legal Issues in Your Medical Practice

All health care professionals including advanced practice clinicians (nurse practitioners and physician assistants) want to prevent any potential legal actions related to the excellent care they provide.

Let me first start off by saying, I am not an attorney and I don’t play one in real life, on TV or on the internet. I had never even been in a real courtroom until recently. However, back in 2006 became involved in an investigation of another health care professional that has only recently gone to trial, and have spent a good amount of time researching the topic for past and future presentations. Thus, I’d like to share just a few tips that you can take to protect yourself as you continue to provide excellent care to your patients.


First and foremost, pay attention to your documentation! Make sure it tells the story, discusses your findings, your assessment and your plan. Whoever is reading the note, should be able to understand how you got to your proposed plan AND be able to pick up where you left off, making any necessary adjustments.

Don’t assume that someone can read your mind and don’t assume you will remember 1, 6 or 52 weeks later. While not everyone is able to complete each and every chart in the room before the patient leaves, make serious attempts at getting your charting done as soon as it’s feasible. Memory fades over time. Need a refresher on documentation? Here is a primer on documentation published by CMS-(The Centers for Medicare and Medicare Services) Search their site for “Documentation Guidelines for Evaluation and Management (E/M) Services”

Coding and Billing:

You may not be doing the billing in your office, but chances are you are responsible for coding the level of the visit. It’s your responsibility to be aware of the requirements for level of care regardless if your CPT code reflects the work and acuity of the patient, or the time spent. Make sure you have documented accordingly. If you need to brush up on your E&M coding skills, you can get some great free education at http://www.emuniversity.com. Coding the wrong level of service, or even “incident to” inappropriately, can land you in hot water.

Medication Errors:

Believe it or not, medication errors continue to be quite common. In fact, according to the 2009 NP claims study*, more than 80% of medication errors are prescription-related and 1/3 of those involved prescribing the WRONG medication.

Make sure you check and double check your prescriptions for spelling, dose, indication, side effects and contraindications. If you are using any of the electronic prescribing tools available, it should help, but they are not foolproof. Take advantage of the various tools you can use in the room with you including those on your PDA or smartphone. Epocrates, my favorite is only one of the various tools available.

Protect Yourself:

If you have legal concerns, it’s always best to check with an attorney who is familiar with health care, advanced practice issues, and is in your state. Make sure you have appropriate liability coverage. All healthcare providers today have a tremendous responsibility to do the best they can do, often under less than ideal situations. Despite this, we continue to do our best to provide the best level of care we can for our patients and clients. These suggestions can help protect you (and your patients) even years into the future.

*2209 NP Claims Study can be found at http://www.nso.com Once there, search for the following search terms to see the report: “2009 NP claims study”

Legal Research – How to Find & Understand the Law

“Legal Research: How to Find & Understand the Law” by Attorney Stephen Elias and the Editors of Nolo is another book in the huge legal library published by Nolo, a publisher that prides itself on making the law accessible to everyone. I’m an attorney, and I still like the books put out by Nolo, especially the ones on areas I’m not as familiar with, but want a little knowledge. Nolo always delivers.

Not everyone can afford Lexis or Westlaw, the two biggest subscriber based on-line legal resources. In law school we had access to both, because both companies wanted to earn your loyalty for when you got out and started practicing. Many firms have one or the other, and I suppose large firms may subscribe to both. Even with access to one of these, I find that I can often find things faster and easier with free resources. Many states have statutes and such on-line these days. More and more are becoming available all the time.

That’s where the book “Legal Research” comes in. It provides easy to follow research methods to help you answer your legal questions. The book has sections for on-line research as well as information regarding law libraries for those who have access to one.

The book consists of 386 pages divided among ten information packed chapters. The chapters include:

One: Understanding the Basics of the Law. Brief descriptions of what the law is, sources of law, state versus federal law, and the court system. Too basic for an attorney, but for the layperson the book was written for, this is a good introduction.

Two: Finding Legal Resources. This chapter explains where legal information is located, primary and secondary sources, internet resources for legal topics, and legal research websites. It includes Lexis and Westlaw, but also other sites that are free. I like the tips and warnings through out the book as well. Good caution that not every opinion you find is good law. Obvious to someone who had it drilled into them during law school, but probably not known to many laypeople.

Three: Identifying Your Legal Issue. Things to know before you go looking, like is the case civil or criminal, figuring out the area of law you want to research, what resources will help you with what you need to find, and figuring out your legal research question. This is important, you want to know what you’re really looking for before you go searching.

Four: Finding and Using Secondary Sources. This chapter explores sources such as online resources (including a bit about deciding if reliable), self-help legal books, legal encyclopedias, form books, practice manuals, continuing legal education publications, law reviews, and so on. Many law firms will have a lot of these kinds of resources, and you will find even more at a law library. This chapter gives a brief overview of what these sources are.

Five: Finding and Using Constitutions, Statutes, Regulations, and Ordinances. These are the bulk of legislatively or administratively created law. This chapter explains how to find these resources and how to use them. It covers finding and using constitutions, finding federal statutes, finding state statutes, understanding them, finding regulations and other rules and ordinances. All of these are important depending on your particular issue. This chapter is a good introduction to this world of “laws” for those that are charting unfamiliar territory.

Six: Finding Cases. Some of our law is not found in statutes, but in the decisions of cases that have already been decided. These cases interpreted laws and are now the rule until legislature changes it, or another case overrules it. Roe v. Wade is an example of a famous case that is looked to regarding abortion law. This chapter helps the reader learn how to use citations to find cases, find cases on the internet, find cases in the law library.

Seven: Using Case Law. This chapter actually explains what a case is, how they are published, and how cases affect later disputes. If you matter relies on case law, this chapter will help you.

Eight: Validating Your Research. I pointed out the tip earlier, and this chapter goes further to help you make sure you have “good law.” It teaches you how to Shepardize a Case, a process we lawyers use to ensure the cases we are relying on are still good. If you are trying to make a case yourself, you must be sure you are relying on “good law.” These are the kinds of things lawyers know that many laypeople don’t.

Nine: Organizing and Putting Your Legal Research to Use. One thing clerks, legal interns, and associates spend a lot of time doing is research. Once you find the information, you must put what you find in written form for those that asked you to find it. This chapter provides the basics for writing a legal memorandum. Not as thorough as the semester class most first year law students take, but good for the non-lawyer. There is a brief section about going to court and the court process and about a couple pages on finding and working with a lawyer.

Ten: Research Hypothetical and Memorandum. Maybe it is because lawyer learn by case studies and examples that this chapter provides a research problem, how to discover the facts, and then how to approach the question to research. It’s very short, so it will give the non-lawyer a little example of how to look at the law and go about finding your answer.

The book chapters stop here on page 255. The next 100 plus pages is a glossary, which a person would not need if they have a legal dictionary. Nolo actually has a simple legal dictionary that won’t replace “Black’s” but is a good resource. Then there is a short appendix on topics and an index.

Overall, I think this book could be very valuable for the person who wants or needs to do legal research but does not know where to start. If you are forced to do-it-yourself, this guide can lead the way. It is a very good description of the legal research process for those without a law degree.

The Mystery of Hillary Clinton’s Astrology Chart

As the 2008 Presidential race heats up, astrologers are somewhat at a loss in making predictions because two of the major players’ birth times are unknown-Hillary Clinton and Barak Obama. For Hillary, the two most commonly given times are 8:00 a.m. and 8:00 p.m. Central Standard Time on October 26, 1947, in Chicago, Illinois. In one chart, she has Gemini Rising, while in the other she has Scorpio Rising. The two Midheavens-the career point at the top of the chart-are opposite one another – 4° Virgo in Chart 1 versus 5° Pisces in Chart 2. The house positions of the planets, however, are not all opposite one another in the two charts, so the house placements ought to be revealing.

In general, with a questionable birth time, I’d recommend against making a snap judgment based on the rising sign. So many factors could affect how the rising sign is expressed: planets in the 1st house; planets that make hard aspects to the Ascendant itself; and the sign, house placement, and aspects of the ruler of the Ascendant. For instance, Pluto square the Ascendant would give a certain Scorpionic cast to the outward personality, though not as obviously as with Pluto conjunct the Ascendant. Uranus conjunct the Ascendant could make for an Aquarian type – in spades. A Leo-rising person with the Sun (Leo’s ruler) in Cancer in the 12th would not necessarily register as Leonine.

In Hillary Clinton’s case, however, the differences between the two Ascendants are suggestive. The 8:00 p.m. time gives Gemini rising, with Uranus in the 12th house conjunct the Ascendant. It’s true that Hillary espouses liberal causes, yet Uranus conjunct the Ascendant should indicate more of a rebel or maverick, and with Uranus in the 12th house, her involvement might be likely to backfire on her. The 8:00 a.m. chart, with Mercury in Scorpio in the 12th conjunct the Ascendant, makes a bit more sense. She’s a potent speaker, political to the core, shrewdly analyzing every move. Yet, her shrewdness shows through a bit too clearly, making her less than beloved by some segments of the population. In either case, however, the Ascendant has a Mercurial tinge to it – Gemini rising vs. Mercury conjunct the Ascendant – so we must remain undecided at this point.

The 12th house is extremely prominent in the 8:00 a.m. chart, with four planets (including personal ones – the Sun, Mercury, and Venus – and Chiron) in Scorpio. It’s a popular misconception that 12th -house types tend to fade into the background: George W. Bush also has the Sun in the 12th, along with Saturn. All we can say for certain about a 12th-house Sun is that the person’s true self is hidden from the general public. Since the 12th is traditionally the house of secret enemies and “self-undoing,” Hillary’s stellium might be relevant to the political scandals that tarnished the Clinton administration. The 12th -house Venus-Chiron conjunction in Scorpio might also partly explain her apparent tolerance of Bill Clinton’s sexual dalliances. (With a completely unknown birth time, it would be hard to say whether Pluto or Scorpio was operating in the 12th – recall what I said earlier about false positives.)

Uranus is the only planet in the 12th in the 8:00 p.m. chart; the 5th house is prominent instead, with three Scorpio planets plus Neptune in Libra. This combination does not ring true. Even though former First Daughter Chelsea Clinton is clearly a much-loved child, with that stellium in the 5th you would not expect an only child, but rather a lively brood. (Of course, not everyone with a strong 5th house has children; for instance, some of these natives are creative artists or performers, and some work with children as a career.) On the basis of our analysis so far, I am leaning toward the 8:00 a.m. chart.

The biggest remaining difference is the placement of the triple conjunction of Mars, Saturn, and Pluto in Leo. In the 8:00 a.m. chart, these planets are in the 9th house; in the 8:00 p.m. chart, they are in the 3rd. Yes, having the trio in the 3rd house (communication and thinking) of the 8:00 p.m. chart could fit Hillary’s penetrating mind and powerful speaking ability. However, that quality could also be accounted for in the 8:00 a.m. chart by Mercury on the Ascendant, closely square Saturn and trine the Moon. The placement of this planetary trio in the 9th house in the a.m. chart also shows Hillary’s Ivy League law school success and persistent activism in legislation. Mars, Saturn, and Pluto in the 9th might also represent the legal battles and even dirty politics that she has become entangled in, including several legal actions taken against the Clintons during their years in the White House.

Finally, the transits to the a.m. chart make the most sense, with Saturn transiting the 9th house, given her highly political stance and congressional post for the past few years. Saturn has been crossing back and forth over that 4 degree Virgo Midheaven since October, 2007, and she’s been running and running hard for all these months. As a good test of 8:00 a.m. birthtime, Saturn will make its last conjunction to that Midheaven around the first of July, 2008.

If it’s the correct chart, her race for the Democratic Presidential candidate should come to a decision point at that time where she either prevails or quits, and if she quits, we’ll know whether she’s willing to run for Vice President or not. The specifics I can’t predict, but when Saturn crosses one’s Midheaven, they usually get a promotion. The Presidency is the promotion she’s hoping for, but Vice President is a step up from either senator or First Lady.

Legal Nurse Consultant Jobs in Texas – A Logical Next Step For an RN?

If you’re an experienced RN looking for a career change, why not consider becoming a legal nurse consultant? This exciting and challenging career will allow you to use your well-honed medical skills to help attorneys interpret medical records and other medical information as it relates to lawsuits and other legal matters. A successful legal nurse consultant (LNC) skillfully combines medical and nursing skills with legal knowledge.

With concentrated, specialized training in personal injury and medical malpractice law, LNCs are valuable assets to attorneys who need expert opinions cases related to these legal categories. Legal Nurse Consultants can consult on everything from simple personal injury cases, like automobile accidents, to complex and high profile cases involving celebrities, major corporations and well-known products and pharmaceuticals.

Legal nurse consulting is a burgeoning field. It’s estimated that about 25% of the nearly 1,000,000 attorneys practicing in the United States handle personal injury and medical malpractice cases. Although highly skilled in legal matters, many attorneys don’t know how to read medical records and charts. In addition, the terminology in these records often requires interpretation or clarification. A legal nurse consultant is a valuable asset to these attorneys, since he or she has a background in case law and the civil litigation process that compliments his or her formal medical training.

Since the services of LNCs are charged on a fee basis, much like attorneys, the field is particularly lucrative. A typical fee of about $20,000 would include the following services provided by a LNC to an attorney:

– Analysis of medical records associated with the case
– Preparation of any necessary trial exhibits
– Preparation of witnesses for both deposition and trial testimony
– Attendance at trial
– Preparation of questions for cross-examination

In Texas, projections from the Bureau of Labor Statistics show that nursing will be the fastest growing occupation over the next five years. Historically, nursing jobs provide long-term stability. The Texas Center for Nursing Workforce Studies estimates that the demand for nurses in the state will grow by 86% while the supply will grow by only 53%. The need for legal nurse consultants is expected to experience similar growth.

The state of Texas has a diverse, vibrant and highly productive economy. While Texas is typically known for oil production, it also is a leader in agriculture, with more farmland than any other state. Texas ranks second in overall cost of living in the United States and is a leader in high tech and manufacturing jobs. The job outlook for Legal Nurse Consultants in Texas is expected to remain positive for many years to come.