Mastering Medical Records in the 21st Century | Professional Education Group


Mastering Medical Records in the 21st Century

Samuel D. Hodge Jr.

Medicine has entered the digital age with electronic medical records and e-prescriptions. Nevertheless, every time a client visits a health care provider, a record is made—a history of complaints, the physician’s observations, and prescribed treatment. Each record is unique, handwritten in a doctor’s shorthand with abbreviations and codes with no uniformity among offices.  So, when you need to understand and use medical records in a case, not only must you go through the machinations to retrieve those records in view of HIPAA and other invasion of privacy mandates, but you must also translate their contents—a daunting task hampered by jargon, abbreviations, unfamiliar word usage and various digital

Sam’s unmatched energy, graphics-intense format and entertaining delivery guide you to case clarifying sense as he shares productive litigation tips regarding:

  • how physicians and hospitals organize records and how you should re-organize them to make litigation sense
  • electronic medical records – how to understand this new format and determine if they have been altered
  • common medication and medical records errors
  • e-prescriptions
  • spoliation, peer review, HIPPA mandates, and the crossroad of medical and legal ethics
  • novel court cases on medical records and tips on conducting medical research
  • practice tips and litigation references every step of the way


Program Outline & Schedule (6 hours)

[Part I: 90 minutes]

Medical and Legal Ethics
• Ethical issues involving medical records
• Spoliation of medical records
• Peer reviews
• HIPPA mandates – what you can and cannot do

Obtaining Medical Records
• Methods for retrieving records
• Federal and state rules governing access to medical record and their costs
• Litigation tips for easier access to medical records and what records to obtain


[15 minute break]

[Part II: 90 minutes]

Understanding Medical Terminology
• How medical terms are created
• Defining the terms
• Understanding common medical abbreviations
• Sam’s tips for understanding medical jargon

Organization of Medical Records
• Medical records organization
• The jargon of prescriptions, common drug abbreviations, mistakes and e-prescriptions
• Routes of drug administration
• What the medical abbreviations mean and why mistakes are made in recording and reading those abbreviations
• The “do not use list”



[Part III: 90 minutes]

Electronic Medical Records
• The use and limitations of electronic medical records
• How to determine if electronic medical records have been altered

Types of Medical Records
• Contents of the hospital chart versus the treating physician’s records
• The SOAP format
• Classifications of surgeries
• The emergency room record
• The admissions process and triage


[15 minute break]

[Part IV: 90 minutes]

Diagnostic Procedures
• Learn about the blood tests
• Common diagnostic procedures performed on the body

Legal Issues
• Learn how to do medical research
• How long medical




Unconditional Guarantee
If you are not convinced that your understanding of the course topic has
improved after completion of any
P.E.G.® seminar, we will refund your course tuition.