Medical
Records 101, Lesson 3
Building
Your Medical Library
Janabeth F. Taylor,
R.N., R.N.C.
Whether your practice involves a client injury in the workplace, injury due to medical negligence, product defect, or toxic chemicals you will have a need to obtain and review medical records.
At times the terms used in the medical records can be confusing and the rationale fordiagnosis and treatment is not clear. In other instances you wish to review a standard of care as it relates to your client’s diagnosis and treatment.
Below is a general listing of resources, both in text print as well as online which might be of benefit to your office.
We are all sensitive to the issue of overhead for the law office. Therefore, you may want to consider obtaining some of these books as library materials for a shared legal medical library established through your local bar association or in co-operation with other law firms in your immediate area.
Medical Abbreviations: 24,000 Conveniences at the Expense of Communications and
Safety
by Neil M. Davis
Temple Univ., Philadelphia, PA.
Annual pocket quickreference guide to 24,000 meanings of medical abbreviations and 3,400 crossreferenced generic and
brand drug names. Thumbtabbed pages. Includes singleuser access code to the Internet version of the book which is updated with 80120 new entries per
month. Softcover.
Paperback: 430 pages
Publisher: Neil M. Davis Assoc; ; 11th edition (December 2002)
ISBN: 0931431115
Laboratory and Diagnostic Tests with Nursing Implications (6th Edition)
by Joyce Lefever Kee, RN, MSN
Each test is discussed in seven subsections in the following sequence: (1) reference values/normal findings, (2) description, (3) purpose, (4) clinical problems, (5) procedure, (6) factors affecting laboratory or diagnostic results, and (7) nursing implications with rationale. Following the name and initials for each test, there may be names of other closely associated tests. Reference values/normal findings are given for children and adults, including the elderly. The description focuses on background data and pertinent information related to the test. The general purpose for each test is listed. Clinical problems include disease entities, drugs, and foods that cause or are associated with abnormal test results. The procedure is explained with a rationale for the test and with appropriate steps that the nurse and other health professionals can follow. Factors affecting laboratory or diagnostic results alert the nurse to factors that could cause an abnormal test result. The last subsection and most valuable information for each test concerns the nursing implications with rationale. For most diagnostic tests, nursing implications are given as “pretest” and “posttest.”
Paperback: 805 pages ; Dimensions (in inches): 1.25 x 9.50 x 7.25
Publisher: Prentice Hall; ; 6th edition (September 12, 2001)
ISBN: 0130305197
Alexander’s Care of the Patient in Surgery
by Jane C. Rothrock, RN, DNSC, DN0R, FAAN (Editor), Dale A. Smith, RN, CNOR, RNFA (Editor), Donna R. McEwen, RN, BSN, CNOR, CRST (Editor)
ALEXANDER’S CARE OF THE PATIENT IN SURGERY, considered the standard in perioperative care for over 50 years, is a comprehensive reference for students and practitioners alike. Unit I covers basic principles and patient care requisites. Unit II details stepbystep procedures for over
400 general and specialty surgical interventions. The unique needs of ambulatory, pediatric, geriatric, and trauma surgery patients are discussed in Unit III. New features include highlighted patient education and discharge planning, sample critical pathways, expanded coverage of endoscopic/minimally invasive procedures, and internet resources. A new chapter, Surgical Modalities, addresses today’s technologically advanced perioperative environment.
Hardcover: 1409 pages
Publisher: MosbyYear Book; ; 12th
edition
(January 15, 2003)
ISBN: 0323016227
Merck Manual Diagnosis & Therapy (Includes Facsimile of 1st ed. of the Merck Manual)
by Mark H. Beers (Editor), Robert Berkow (Editor), Mark Burs (Editor)
The most widely used medical text in the world and the hypochondriac’s bible, the Merck has the lowdown on the vast expanse of human diseases, disorders and injuries, as well as their symptoms and recommended therapy. It’s intended for physicians and medical students, but though the type is tiny and the language technical, the Merck’s a valuable volume for anyone with more than a passing interest in bodily ills.
Leather Bound: 2833 pages
Publisher: Merck & Co; 17th edition (March 5, 1999)
ISBN: 0911910107
Rosen’s Emergency Medicine: Concepts and Clinical Practice (3Volume Set)
by John, Md. Marx, Robert, Md. Hockberger (Editor), Ron, Md. Walls (Editor), Robert S. Hockberger
ROSEN’S EMERGENCY MEDICINE continues to be the premier source that defines the field of emergency medicine. It describes the science of emergency medicine and its application, focusing on the diagnosis and management of problems encountered in the emergency department. This stellar new team of editors has introduced many new features including a “Cardinal Presentations” section, chapter consistency, and more diagnostic imaging throughout. All existing chapters have been extensively revised, and reference lists have been edited to include more significant, uptodate
references.
Hardcover: 2766 pages
Publisher: MosbyYear Book; 5th edition
(January 15, 2002)
ISBN: 0323011853
Joint Commission on Accreditation of Healthcare Organizations. (CAMH) Comprehensive Accreditation Manual for Hospitals: The Official Handbook: Accreditation Policies, Standards, Scoring, Aggregations Rules, Decision Rules.
Oakbrook Terrace, IL, Joint Commission on Accreditation of Healthcare Organizations, 2001. CAMH, $350.00; CAMH and 1year
update, $565.00; CAMH annual subscription update, $245.00.
Cecil Textbook of Medicine (Single Volume)
by Russell L. Cecil (Editor), J. Claude Bennett (Editor), Lee Goldman (Editor)
Cecil Textbook of Medicine, 21 Edition CDROM provides rapidaccess to the complete text, illustrations, tables and references. Review questions with answers are linked to the relevent sections of the textbook and complete drug monographs from Mosby’s GenRx are included. Plus, this CDROM gives you FREE access to
Cecil Online! This text refers to the CDROM edition.
Hardcover: 2308 pages
Publisher: W B Saunders; (January 15, 2000)
ISBN: 072167996X
Current Pediatric Diagnosis & Treatment
by William W. Hay, Jr, MD (Editor), Anthony R. Hayward, MD (Editor), Myron J. Levin, MD (Editor), Judith M. Sondheimer, MD (Editor)
Provides clinical information on ambulatory and inpatient medical care of children from birth through adolescence, focusing on clinical aspects of pediatric care and their underlying principles. Emphasis is on ambulatory care, acute critical care, and a practical approach to pediatric disorders. This edition contains new chapters on developmental disorders and behavioral problems, substance abuse, allergic disorders, and fluid, electrolyte, and acidbase
disorders and therapy, plus expanded illustrations.
Paperback: 1320 pages
Publisher: Appleton & Lange; 16th
edition (October 25, 2002)
ISBN: 0071383840
Clinical Nursing Skills & Techniques
by Anne Griffin Perry, Patricia Ann Potter, Anne G. Perry, Patricia A. Potter
The 5th edition of Clinical Nursing Skills and Techniques offers new uptodate
content and improved features, in addition to complete coverage of more than 200 nursing skills, a nursing process framework for a logical and consistent
presentation, and a convenient 2column format with rationales for each skill step.
Paperback: 1320 pages
Publisher: Mosby, Inc.; 5th edition (June 15, 2001)
ISBN: 0323014062
ACEP - Critical Decisions
Critical Decisions in Emergency Medicine, reliable, relevant clinical updates/risk management. two lessons each month. Subscription for non member $244 a year.
Index of past issues found at: http://www.acep.org/1,5012,0.html
Order by calling ACEP or going to http://www.acep.org
and order online
ACEP - Foresight CEU Risk Management
Example: http://www.acep.org/library/pdf/Foresight56.pdf
Print monthly from online resource.
AMA - Medicolegal Forms with Analysis - Documenting Issues in the PatientPhysician Relationship.
Covers issues such as consent, informed refusal, ama, and others. Contains current forms and references to legal citations related to each issue discussed.
Binding: Hardcover
Publisher: American Medical Association
Published Date: 06/01/1990
List: USD $32.00
ISBN: 0899704026
Other Suggested Book Lists/Links
Brandon/Hill selected list of print books and journals for the small medical library
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11337945
“Selected List of Books and Journals for the Small Medical Library” was published almost forty years ago, this series of selection guides has been heavily used and highly valued by librarians, nurses, health care practitioners and publishers. The Small Medical Library list was followed in 1979 by the “Selected List of Nursing Books and Journals” and by the “Selected List of Books and Journals in Allied Health Sciences” in 1984. In 2001, the publications were made available on the internet, promoting unrestricted access.
It was always the instruction of Alfred Brandon and Dorothy Hill, the original authors, that the selected lists would not be published under their names without their direct involvement which is why they retained copyright of the lists. With the recent retirement of Dorothy Hill, this longstanding project has drawn to a close.
Brandon Hill Journal Links -
http://nnlm.gov/libinfo/ejournals/branhill.html
This list of Journals available in full text online was updated on a regular basis by the National Library of Medicine through May 12, 2003, This page is valuable in terms of information to online resources, but this page, “MLA Brandon/Hill Journal Links”, is no longer updated.
General Reference Internet Links
Medscape
http://www.medscape.com
Medscape is a multispecialty Web service for clinician and consumers that combines information from journals, medical news providers, medical education programs, and materials created for Medscape. Here you will find a combination of peerreviewed publications, a free version
of drug information via the “First Data Bank File” and free Medline.
MD Consult
http://www.mdconsult.com
Founded by leading medical publishers that include Mosby and W.B. Saunders, MD Consult integrates peerreviewed
resources from over 50 publishers, medical societies, and government agencies. From this site you can obtain full text from respected medical reference books from a variety of specialties, medical journals, and MEDLINE. In addition you can obtain comprehensive USP drug information (beyond the scope of a PDR), as well as more than 600 clinical practice guidelines. This is not a free service, but for a small fee you can have access by the day, month or year. Also there is a free seven day trial membership.
Guidelines Clearing House
http://www.guidelines.gov
This site is a public resource for evidence based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans. A medical term search will retrieve objective, detailed information on clinical practice guidelines. Results in a search will obtain: structured abstracts (summaries) about the guideline and its development, a utility for comparing attributes of two or more guidelines in a sidebyside comparison,
syntheses of guide-lines covering similar topics, highlighting areas of similarity and difference, links to fulltext guidelines,
where available, and/or ordering information for print copies and, annotated bibliographies on guideline development methodology, implementation, and use.
CPT Codes -
http://www.ama.org
This website gives users of CPT the opportunity to perform CPT code searches and obtain information about Medicare’s relative value payment amount associated with the codes. Searches can be performed using 5 digit CPT code numbers or key word(s) in the code description. Also you can order the CPT coding handbooks in paperback format. The codes are updated annually.
Additional Internet Resources
Anatomy
http://www.anatomy.org/i4a/pages/index.cfm?pageid=1
Anesthesiology
http://www.abanes.org
http://www.asahq.org
Cardiology
http://www.acc.org
http://www.augusta.net/atlantic/ascp.ascpscm.html
http://www.asecho.org
http://org.umc.edu/iash/homepage.htm
http://www.americanheart.org
Chiropractic
http://www.amerchiro.org
http://www.accoweb.com
http://www.chiromed.org
http://www.nysca.com
Emergency Services
http://www.aaem.org
http://www.abem.org
http://www.acep.org
Endocrinology
http://www.aace.com
http://www.womeninendo.org
http://www.diabetes.org
Gastroenterolgy/Liver
http://www.acg.gi.org
http://www.gastro.org
http://www.asge.org
http://www.sgna.org
http://www.liverfoundation.org
General Medicine
http://www.aafp.org
http://www.abms.org
http://www.amaassn.org
http://www.aamc.org
http://www.msweb.net/aaps/
Hematology
http://www.hematology.org
Iatrogenic Injuries
http://www.iatrogenic.org
Immunology
http://www.ashihla.org/
http://www.aaaai.org
Infectious Disease
http://www.idac.org/idlinks.html
http://pages.prodigy.net/pdeziel/
http://www.cdc.gov/ncidod/id_links.htm
http://www.amm.co.uk/
Internal Medicine
http://www.acponline.org
http://www.abim.org
http://www.sgim.org
Obstetrics/Gynecology
http://www.acog.org
http://www.abog.org
http://www.accesspub.com/tempobg/soc/socm.htm
Midwifery
http://www.acnm.org
Neurology
http://www.stroke.org/
http://www.aan.com/
http://www.neuroguide.com/
Oncology
http://www.asco.org
http://www.cancernet.nci.nih.gov
http://www.oncolink.upenn.edu
http://www.cancer.org
Opthamology
http://www.eyenet.org
http://www.ascrs.org
http://www.asoprs.org
http://www.glaucomafoundation.org/info/
Optometry
http://www.aaopt.org
http://www.aoanet.org
Orthopedics
http://www.aaos.org
http://www.sportsmed.org
Pediatrics
http://www.aap.org
Pharmacy
http://www.aphanet.org
Physical Therapy
http://www.aaptnet.org
http://www.apta.org
http://www.nationalrehab.org
Physiology
http://www.faseb.org/aps/
Plastic Surgery
http://www.facialplasticsurgery.org
http://www.plasticsurgery.org
Podiatry
http://www.apma.org
http://www.footandankle.com/podmed/
Preventative Medicine
http://www.acpm.org
Psychiatry
http://www.abpn.com
http://www.psych.org
Pulmonology
http://www.lungusa.org
http://www.aarc.org/
http://www.chestnet.org/
http://www.thoracic.org/
Radiology
http://www.asrt.org
http://www.rsna.org
http://www.acr.org
Rheumatology
http://www.rheumatology.org
http://www.arthritis.org
Surgery
http://www.facs.org
http://www.acfas.org (foot and ankle)
http://www.fascrs.org (colon and rectal surgeons)
http://www.womensurgeons.org
Urology
http://www.auanet.org
http://www.kidney.org
Vascular Medicine
http://www.svmb.org
Veterinary Medicine
http://www.abvp.com
http://www.avma.org
Medical Terminology
http://mywebmd.com/encyclopedia
http://www.nlm.nih.gov/medlineplus/mplusdictionary.html
http://medmatrix.org
http://www.edae.gr/dictionaries.html
http://www.medicinenet.com (then click on dictionary)
http://www.4woman.org/nwhic/references/dictionary.htm
(online med dictionaries and journals)
Large Listing of Medical Related Sites
http://www.sciencekomm.at/links/medicine.html
Janabeth F. Taylor, R.N., R.N.C. has a degree in Nursing from Oklahoma State University and Litigation Paralegal Certificate from the University of Oklahoma Law Center. She was a nursing instructor for ten years and has been a medical legal consultant since 1990. Ms. Taylor is currently President/Owner of Attorney’s Medical Services, Inc. in Corpus Christi, TX.
In 2002 she was named the Association of Trial Lawyers of America’s Paralegal of the Year. She provides litigation support for attorneys across the United States and specializes in case reviews and Internet information resources. Her website is http://www.attorneysmedicalservices.com and her email address is
jana@attoneysmedicalservices.com
|
