What records does a nurse life care planner review?

Q. What records does a nurse life care planner review?

A. A nurse life care planner will want to see all available records. Sometimes when records have been compiled by a paralegal or other nonmedical person, they are incomplete because the compiler does not recognize the significance of each piece.

For example, EMS and emergency department records describe initial findings and mechanism of injury. While admission and discharge summaries are useful, they are often dictated by residents who are not completely up to date on the range of care and responses during the admission; it is often surprising to see conflicts and errors in them.

The life care planner will want to review all team progress notes, laboratory and diagnostic studies, physician order sheets, nursing records, medication administration records, consultant notes, and procedure notes (e.g., surgery, invasive testing). Outpatient therapy and orthotics/prosthetics records include periodic evaluations as well as notes from each session; problems, absences, and adherence to teaching are found here. For a child, school records, IEP (individual education plan), and pediatrician notes are important to assess current developmental state and function.

Police accident reports would help the nurse to understand possible mechanisms of injury, and to assess for signs of disability that may not have been evident during initial hospitalization.

Finally, billing records can reveal valuable information on physicians and treatment plans that may need to continue in a life care plan.

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