Review Course Test Taking Tips & Sample Questions

Review Course Test Taking Tips & Sample Questions
Julie Dickinson, MBA BSN RN LNCC Karen J. Huff, BSN RN LNCC September 12, 2012 The educational content contained in this webinar is current and accurate and contact hours will be awarded through December, 2014.

Speaker Introductions
Julie Dickinson Karen Huff Our speakers today are Julie Dickinson and Karen Huff, course coordinators. [Speaker introductions to be read by Kathryn, our Moderator.]

CONFLICT OF INTEREST Julie Dickinson and Karen Huff hearby certify that, to the best of our knowledge, no affiliation or relationship of a financial nature with a commercial interest organization has significantly affected their views on the subject on which they are presenting.

Schedule for Webinar Series
DATE TOPICS SPEAKERS Webinar #1 01/18/12 Medical Malpractice Elder Law Julie Dickinson Karen Huff Webinar #2 02/01/12 Personal Injury Forensics / Criminal Kathy Ferrell Diane Reboy Webinar #3 02/15/12 Product Liability Toxic Torts Regulatory Compliance Rosie Oldham Catherine Beasley Rosie & Catherine Webinar #4 02/29/12 Life Care Planning Worker’s Comp Risk Management Patty Costantini Webinar #5 03/14/12 Administrative Health Law Test Taking Tips Practice Questions Julie & Karen Webinar #6 09/12/12 Julie Dickinson & Karen

Objectives for Today’s Webinar
Describe 3 ways a legal nurse consultant can prepare for the LNCC examination. List 4 test-taking tips. Identify 3 LNC skills that the LNCC examination is designed to measure.

LNCC Review Course: Test Taking Tips
Karen J. Huff, BSN RN LNCC September 12, 2012

Preparing for the LNCC Exam
Review LNCC Exam Handbook Study Materials & Other Resources Intellectual Preparation Learn about the test itself

LNCC Application Handbook
Includes application deadlines, list of study guides, eligibility requirements, exam information To download, LNCC website has additional information at or

LNCC Eligibility Requirements
Coming in 2013 ……revised ALNCCB guidelines for Eligibility requirements / Practice Hours 2000 hours in five years (rather than 3 years) to sit for initial exam, same as recertification requirements Recertification Increased options for types of activities eligible for CEs Visit ALNCCB Booth at the Forum for more info!

Emotional Preparation
A little anxiety is a good thing. Severe anxiety (test anxiety) impairs test performance. Feeling intellectually prepared is the best anxiety reducer for most people. If you need special accommodations for a disability, request them.

Study Materials & Other Resources
Legal Nurse Consulting Principles, Legal Nurse Consulting Practices (AALNC’s core curriculum) LNCC Practice Exam LNCC Review Course (this course!) Reading list prepared for this course Journal of Legal Nurse Consulting (JLNC) Test is not based on the core; we’ll talk about it later – it is based on practice analysis. Address questions about 2nd edition of the Core vs 3rd edition, etc.

Study Materials & Other Resources
Mentors in other areas of practice See additional resources listed in LNCC handbook On-the-job experience helps!!

ALNCCB Disclaimer re Study Materials
Companies called Morrison Media LLC and Kaplan advertise certification preparation programs of study for the Legal Nurse Consultant Certified (“LNCC”) Examination. Neither Morrison Media nor Kaplan are affiliated with American Legal Nurse Consultant Certification Board (“ALNCCB”) or the American Association of Legal Nurse Consultants (“AALNC”). No representatives of either Morrison Media nor Kaplan have any involvement in the preparation or testing of the LNCC examination and the products which they offered are neither sanctioned nor approved by the ALNCCB Mention Morrison Media as a company that claims to have prep materials for multiple nursing exams; this issue has come up at ABNS meetings, and other certification boards have take a proactive stance and are warning consumer about it. 13

Intellectual Preparation
Study in a systematic manner. Plan your study over a period of weeks or months. Individual preparation Study groups Formal review course Combination of strategies

Intellectual Preparation, Cont.
Identify weak areas Make study guides Use your cases Focus most on what you know least Outlines – key points with details for support Think about well done cases – what process did you use?

Physical Preparation Get sufficient sleep prior to the exam.
Eat something before the exam. Be sure you know the location of the test site. Gather together your photo ID, RN license, exam permit. Bring a sweater or jacket. Rooms are often cool. Use bathroom before entering testing site Bring a watch for monitoring time. (It’s a four-hour test.) Many of these “tips” are common sense, but may be helpful to think about these as you prepare.

Learn About the Exam LNCC Blueprint Scope of the Exam
Style of the Exam Scoring & Reporting

LNCC Test Blueprint Axis 1 - Practice Areas % of Test
Medical Malpractice 27-31% Personal Injury 19-23% Product Liability/Toxic Tort 10-14% Workers’ Compensation 12-16% Risk Management 5-9% Life Care Planning 4-7% Criminal/Forensic 1-4% Administrative Health Law/Regulatory Compliance 4-8% Elder Law 3-6% The next several slides are intended to help you learn about the test itself, how it is developed, and the style of the exam. This slide shows the LNCC exam blueprint which is based on the 2008 Practice Analysis conducted by ALNCCB. A Practice Analysis, also known as a Job Analysis, is required by ABNS standards every 5 to 7 years. ALNCCB will be conducting a Job Analysis beginning later this year (2012), with results available in Each time a Job Analysis is done, the blueprint is updated accordingly.

Scope of the Examination
The LNCC examination is designed to measure the nurse's ability to: Collect and investigate healthcare records, research, literature, standards, guidelines, laws, costs, etc. related to a case, concerning issues of standards of care, causation, and/or damages. In addition to the blueprint, the scope of the exam is based on groups of tasks

Scope of the Examination, Cont.
Analyze data in pertinent medical records, research, literature, standards, guidelines, laws, costs, etc. related to a case, concerning issues of standards of care, causation, and/or damages. Facilitate communication between clients (e.g., attorney, claims manager, agency) and parties, experts, witnesses, and vendors.

Draft materials considered attorney work product or to be used as evidence in healthcare-related cases. Educate oneself and clients on the health sciences pertaining to issues in a case. Collaborate with clients to support case strategy during discovery or case management.

Support the process of adjudication of cases (e.g., trial, settlement, arbitration, or mediation). Testify as an expert opinion or fact witness.

Style of Exam Case Set of Questions Individual Knowledge Questions
Most questions are written in case sets, with an introductory medical-legal situation, followed by a series of test questions Individual Knowledge Questions Questions are multiple choice ONLY one right answer! The majority of the exam is written in case sets, meaning the applicant is given a narrative style paragraph or scenario that sets up the facts of the case and the LNC role, followed by a series of questions. There are also some individual knowledge questions. All questions are multiple choice, and there is only one right answer!

Scoring and Reporting 73% correct required to pass.
Score converted to standard score. Standard score of 95 = passing. Average pass rate Persons who do not pass are given breakdown (% correct) by blueprint area, type of case. Deleted bullet for average pass rate – info was old (from 2004 to 2007 pass rate was 81.39%. Add updated info when available from ALNCCB.

Test Taking Tips: Myths & Misconceptions
It’s a mistake to change your initial answer. (Not true.) Many questions have two correct answers. It’s better to leave a question blank if you’re not sure of the answer. Usually 1st instinct is right; be sure you did not mis-read the ?

Test-taking Tips: Multiple Choice Questions
Read ? Carefully Answer ? in your head Read all choices; eliminate wrong answers More likely to be true Answer the question in your head 1st Be careful to avoid misreading the question. All of above – if 1 option is true – do not chose None; if one is false, do not choose ALL. If at least 2 are correct, All is probably the answer.

Test-taking Tips, Cont. Read entire question
Do not “read into” the question. Answer the question only on the information presented. Skip question if too difficult, or… Come back to difficult questions Look for key words - bolded & italicized; first, next, except, not, but….. Focus on your test – do not look like a cheater; you do not need to answer every ? correctly Difficult ? – helps you to focus on main point; Rephrasing can make it clear to you, but be sure you don't change the meaning of the question.

Test-taking Tips, Cont. Pace yourself. Be aware of time.
Keep positive/manage anxiety Do not worry about others in the room Proof work if time permits Don’t spend too much time on any one question. It’s better to skip the question for the time being and return to it later.

Test-taking Tips, Cont. Be sure to keep in mind who the LNC is representing (e.g., PLAINTIFF, DEFENSE) in the case. Differentiate legal nursing from attorney actions in the possible answers The term “client” refers to the person or agency who has engaged the LNC’s services (law firm, insurance company, hospital, etc.)

Test-taking Tips, Cont. Legal terms – study concepts or definitions only See med mal section from webinar #1 for examples See AALNC bookstore for resource Legal Terminology Primer Helps the nurse to become familiar with and understand some of the legal terms encountered while practicing legal nurse consulting. The legal terminology primer is being revised by the Education Committee. (current version published in 2003, 60 pages) 30

Good Luck!!! Test-taking Tips, Cont. In summary, be prepared –
Intellectually Emotionally Physically Good Luck!!!

Sample Questions Source: Sample questions that follow are taken from the LNCC® Practice Exam About the LNCC® Practice Exam Developed with the testing company Endorsed by ALNCCB Contains 100 questions based on LNCC blueprint Available for purchase from AALNC at For the remainder of the webinar, we go over questions from the LNCC Practice Exam to give you an idea of what the actual exam is like. The Practice Exam is a good resource to use to help identify weak areas needing further study. You can also time yourself while taking exam; the practice exam, at 100 questions, should be completed in about 2 hours. (The actual test is 200 questions to be completed in 4 hours.) The new Practice Exam is offered online. Please note that unlike other “practice exams” that may be available, the LNCC Practice Exam offered by ALNCCB is the only practice test developed using the same process used to write the actual exam. This means it was developed with ALNCCB’s testing company, and with a psychometrician.

Sample Questions: Medical Malpractice
While eating out, Mrs. Peterson’s 2 ½-year-old son, Joe, choked on a hot dog. He turned blue and collapsed. When the ambulance arrived, the EMT resuscitated and intubated Joe. Mrs. Peterson was told to meet the ambulance at the emergency room of the local hospital. She arrived before the ambulance. Joe was unresponsive when he arrived. The ED physician determined the endotracheal tube was in the esophagus. Joe was reintubated then transferred to the pediatric intensive care unit still unresponsive, where he died 12 hours later.

The most important objective for Mrs. Peterson’s first meeting with the plaintiff attorney and LNC is a. Schedule dates for depositions b. Determine factors explaining the health care providers’ actions c. Identify likely defendants d. Evaluate the family’s expectation for Joe, if he were alive

Rationale: Initial Plaintiff Interview
“Names of all potential health care defendants should be solicited” during the initial interview of Plaintiff. Conklin, M. R. & Fox, K. S. (2010). Communication with clients in the medical malpractice arena. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (229). Boca Raton, FL: CRC Press.

Rationale: a. Schedule dates for depositions b. Determine factors explaining the health care providers’ actions d. Evaluate the family’s expectation for Joe, if he were alive

To determine liability, the plaintiff LNC should initially request which of the following records a. EMT records b. EMT and ED records c. EMT, ED, PICU & pediatrician records d. EMT, ED, PICU, pediatric and birth records

Rationale: Data Collection
“With every plaintiff, the attorney must gather sufficient facts to conduct the appropriate research and factual investigation to guide the plaintiff in choosing an appropriate course of action.” The initial investigation of liability will focus on healthcare providers who cared for Joe before he was stabilized. Conklin, M. R. & Fox, K. S. (2010). Communication with clients in the medical malpractice arena. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (229). Boca Raton, FL: CRC Press.

Rationale: a. EMT records c. EMT, ED, PICU & pediatrician records
d. EMT, ED, PICU, pediatric and birth records

The plaintiff LNC understands the most limiting effect on the size of the award determined by the jury is a. Who gave Joe the hot dog b. Joe has two brothers c. Joe never regained consciousness d. Joe died after being transferred to the PICU

Rationale: Noneconomic Damages
“General [noneconomic] damages are injuries on which the law is unable to place a dollar amount such as ‘pain and suffering.’” “In recent years many states have enacted caps on noneconomic damages. . . A cap on pain and suffering…can significantly limit the recovery.” Limited special damages; minimal suffering; capped general damages Miller, P. Z. (2010). Elements of triage: Effective case screening of medical malpractice claims. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (110, ). Boca Raton, FL: CRC Press.

Rationale: a. Who gave Joe the hot dog b. Joe has two brothers
d. Joe died after being transferred to the PICU

During a routine visit to the obstetrician, Sally Brown has a nonreassuring non-stress test. She is admitted to the hospital for monitoring and trial labor. The next morning fetal heart monitor strips are normal, and Sally begins to have normal contractions. A Pitocin drip is started. Over the next six hours, fetal heart monitor strips demonstrate the fetus’ heart rate frequently decelerates until eventually there are two consecutive three-minute periods where the heart rate drops to 60 beats-per-minute.

After a 40 minute delay, Sally is taken to the operating suite. A female infant is delivered with Apgar scores of 1 at one minute, 2 at five minutes, and 4 at ten minutes. The infant is severely impaired but is discharged after a 13-week stay in the NICU. The Browns contact an attorney.

During review of the original records, the plaintiff LNC finds a labor flow sheet that was not in the copy the attorney received, and it is marked “DO NOT SEND”. Who should the LNC contact, initially? a. Plaintiff attorney b. Medical records supervisor c. Hospital risk manager d. Director of nursing

Rationale: Communication with Attorney-Client
“The LNC should … alert the attorney to the suspected nature and validity of the [medical record] alteration.” D’Andrea, D. D. & Dworniczek, J. (2010). Medical record analysis. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (330). Boca Raton, FL: CRC Press. Concealment Up to atty to decide how to address this

Rationale: b. Medical records supervisor c. Hospital risk manager
d. Director of nursing defense

Ms. Brown tells the plaintiff attorney and LNC the obstetrician examined her several times but did not look at the fetal heart monitor strips. The attorney asks the LNC to a. Obtain Ms. Brown’s affidavit b. Call to verify with the labor nurse c. Draft deposition questions for the obstetrician d. Tell Ms. Brown that it is not relevant to the case

Rationale: Role of the behind-the-scenes LNC in deposition
“More than any other tool in the discovery process, depositions may serve to provide vital information. . . and reveal the strength or weakness of the opposing counsel’s legal position… [LNCs] may be recruited to help draft deposition questions based on their review of medical records and the medical research they have conducted.” DiCecco, K. L. (2010). Discovery and disclosure. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles ( ). Boca Raton, FL: CRC Press.

Rationale: a. Obtain Ms. Brown’s affidavit b. Call to verify with the labor nurse d. Tell Ms. Brown that it is not relevant to the case

To establish damages for the jury, an effective tool is a. Exhibit of the obstetrician’s progress notes from the cesarean section b. Photographs of the Brown family with the infant c. Video of how fetal heart monitoring is used d. “Day in the Life” video of Baby Brown

Rationale: Demonstrative Evidence
“Demonstrative evidence allows the attorney to demonstrate certain issues to the jury in a way that facilitates their understanding of the complex concepts being presented.” “[Day in the Life] films are powerful visual tools that show a typical day in the life of a catastrophically injured client who may be unable to sit through a trial due to their injuries." Reboy, D. L. (2010). Trial preparation and the trial process. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (400). Boca Raton, FL: CRC Press. Zorn, E. & Lanz, M. (2010). Legal nurse consultant practice within a law firm. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices (82). Boca Raton, FL: CRC Press.

Rationale: a. Exhibit of the obstetrician’s progress notes from the cesarean section b. Photographs of the Brown family with the infant c. Video of how fetal heart monitoring is used

Fifty-year-old Daria Simpson was admitted by a hospitalist to a local community hospital with shortness of breath and generalized swelling. Initial arterial blood gases indicated an abnormally low pO2, so oxygen was started. The hospitalist was not notified. During change of shift report, the evening nurse was not given the ABG results, which had been reported to the admitting nurse.

During the evening, Ms. Simpson was singing loudly, seemed confused, and pulled off her oxygen. She said she did not want oxygen. She was given a sedative, and oxygen was not resumed. During the night, Ms. Simpson deteriorated and was found unresponsive without respirations. The Rapid Response Team was called and successfully initiated CPR. She was transferred to the intensive care unit. She never regained consciousness and was transferred to a long-term care facility. Her family filed a law suit.

In preparing the evening nurse for her deposition, the defense LNC will instruct the nurse a. “If you’re unsure, try to remember your nursing principles.” b. “If you don’t understand the question, ask the attorney to repeat it.” c. “Use a single authoritative source to support your answers.” d. “Bring an outline with you to the deposition.”

Rationale: Deposition Preparation
“…The LNC may become involved in the preparation of the attorney’s expert medical witness.” “The witness should…ask the opposing counsel for clarification of unclear or complex questions.” DiCecco, K. L. (2010). Discovery and disclosure. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (155). Boca Raton, FL: CRC Press. Aiken, T. D., & Warlick, D. T. (2010). The law standards of care, and liability issues. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (27). Boca Raton, FL: CRC Press. Review “ground rules”

Rationale: a. “If you’re unsure, try to remember your nursing principles.” c. “Use a single authoritative source to support your answers.” d. “Bring an outline with you to the deposition.”

For which reason may the admitting nurse be found liable? a. Failing to communicate pertinent information b. Allowing Mrs. Simpson up to the bathroom with assist and oxygen c. Initiating oxygen without a physician’s order d. Leaving Mrs. Simpson alone in her bed

Rationale: Standards of Care
“…The basic premise is that HCPs have a duty to adhere to the applicable standard of care…They are required to exercise that degree of reasonable skill and care expected of a reasonable competent practitioner in similar circumstances.” “Communication is crucial today because of the many different ‘players’ involved in the care and treatment of the patient. Communication lines must be open between the health care provider and other health care providers… Otherwise, the patient may suffer injuries…” Miller, P. Z. (2010). Elements of triage: Effective case screening of medical malpractice claims. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (108). Boca Raton, FL: CRC Press. Aiken, T. D., & Warlick, D. T. (2010). The law standards of care, and liability issues. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (16). Boca Raton, FL: CRC Press.

Rationale: b. Allowing Mrs. Simpson up to the bathroom with assist and oxygen c. Initiating oxygen without a physician’s order d. Leaving Mrs. Simpson alone in her bed

Based on the facts of the case, the defense LNC can anticipate a. Procurement of past medical records b. Deposition of laboratory technicians responsible for ABG results c. Preparation of trial exhibits d. Settlement discussions

Rationale: Economics Economics are a major incentive for good case triage for both sides. “If a potential case has low to moderate damages, but the projected number of expensive experts is high and analysis time-consuming, … a defense attorney [may be] spending more than can be saved for the insurer.” Miller, P. Z. (2010). Elements of triage: Effective case screening of medical malpractice claims. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles ( ). Boca Raton, FL: CRC Press.

Rationale: a. Procurement of past medical records b. Deposition of laboratory technicians responsible for ABG results c. Preparation of trial exhibits

Sample Questions: Personal Injury
Barb Barton was a passenger in a car that was hit, broadside, while passing through a green light. She was alert and oriented at the scene, although she was unsure if she’d lost consciousness immediately following impact. At the time of admission, she complained of blurred vision, headache, diplopia and fatigue. Documented injuries included rib fractures, a right hemothorax, hepatic and splenic lacerations requiring splenectomy. con’t 

Prior to the accident, Ms. Barton had a history of alcohol and recreational drug use. Ms. Barton’s attorney files suit. During trial preparation, an IME confirms Ms. Barton suffered a mild head injury with sequelae. The diplopia resolves, but she continues to complain about headaches and fatigue. She has developed symptoms of depression.

Which of these activities will the plaintiff LNC perform first? a. Screen the case for merit b. Obtain medical experts c. Attend an independent medical examination with Ms. Barton d. A detailed medical record chronology

Rationale: Case screening
“The screening process begins when a client or the client’s representative contacts the firm about a potential case… The goal at this phase of the screening process is to obtain enough information to either reject the case right away or accept it for preliminary investigation.” Zorn, E. & Lanz, M. (2010). Legal nurse consultant practice within a law firm. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices (78). Boca Raton, FL: CRC Press.

Rationale: b. Obtain medical experts
c. Attend an independent medical examination with Ms. Barton d. A detailed medical record chronology

To determine if Ms. Barton sustained a head injury, the plaintiff LNC should recommend the plaintiff be evaluated by a neurologist and a. Notify the defense attorney team of her concerns b. Obtain Ms. Barton’s pre-incident medical records c. Amend the complaint to include a head injury d. Write interrogatory questions to be addressed by Ms. Barton

Rationale: Medical Record Analysis
“…The LNC should closely scrutinize the plaintiff’s present and past medical records for clues to alternative causation from pre-existing health problems, prior injuries, medication side effects, and issues of noncompliance.” DiCecco, K. L. (2010). Discovery and disclosure. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (152). Boca Raton, FL: CRC Press. Establish a baseline

Rationale: a. Notify the defense attorney team of her concerns
c. Amend the complaint to include a head injury d. Write interrogatory questions to be addressed by Ms. Barton

The defense attorney will use Ms. Barton’s substance abuse history as a means to a. Dispute the IME findings b. Show breach of duty c. Reduce liability d. Mitigate damages

Rationale: Damages “The monetary value of any claim is based on the perceived value of the plaintiff’s injuries.” Miller, P. Z. (2010). Elements of triage: Effective case screening of medical malpractice claims. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (110). Boca Raton, FL: CRC Press.

Rationale: a. Dispute the IME findings b. Show breach of duty c. Reduce liability

During an airline flight, Deborah Flower was hit in the head when a piece of equipment placed in the overhead compartment by a flight attendant fell. She suffered facial abrasions, neck pain, nausea and dizziness. Immediately upon landing, she was taken to an emergency department. Following examination, Deborah was released without any significant injuries found. con’t 

Soon after the incident, she wrote a letter to the airline demanding monetary compensation for her injuries. The airline’s insurance company made the decision to pay Ms. Flower’s emergency bills. Ms. Flower contacted an attorney since her mild headaches persisted and she claimed to have developed memory problems since the accident.

For which reason is liability clear in this case? a. The insurance company paid Ms. Flower’s bills b. Ms. Flower was compliant in all treatment recommendations c. The flight attendant placed the equipment in the overhead compartment d. There were witnesses to the incident

Rationale: Evaluation of Liability
“In a PI case, it is presumed the defendant in some way caused the injury LNC record review may uncover information that supports the liability of the defense…” Carroll, P. G. (2010). Personal injury and accident reconstruction. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (509). Boca Raton, FL: CRC Press.

Rationale: a. The insurance company paid Ms. Flower’s bills
b. Ms. Flower was compliant in all treatment recommendations d. There were witnesses to the incident

Why might the defense LNC prepare deposition questions for Ms. Flower that includes inquiries about prior accidents? a. To determine if alcohol or drug abuse was a factor in the accident b. To identify an alternative cause to her symptoms c. To determine is she is accident-prone d. To determine if she was responsible for the other accidents

Rationale: Evaluation of causation
The plaintiff’s past medical history should be scrutinized “for clues to alternative causation from pre-existing health problems, prior injuries, medication side effects, and issues of noncompliance.” DiCecco, K. L. (2010). Discovery and disclosure. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (152). Boca Raton, FL: CRC Press. Establish a baseline

Rationale: a. To determine if alcohol or drug abuse was a factor in the accident c. To determine is she is accident-prone d. To determine if she was responsible for the other accidents

Several months after the accident, Ms. Flower is diagnosed with a brain tumor. The plaintiff LNC should realize a. Ms. Flower will require an examination by a neurologist to confirm the diagnosis b. This will delay settlement c. The defense does not need to be informed of the brain tumor d. The settlement in this case is likely diminished

Rationale: Evaluation of causation
“During the course of a case investigation, as new facts are developed, the LNC should rethink causation and how the new information fits the existing causation piece.” Miller, P. Z. (2010). Elements of triage: Effective case screening of medical malpractice claims. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles (111). Boca Raton, FL: CRC Press.

Rationale: a. Ms. Flower will require an examination by a neurologist to confirm the diagnosis b. This will delay settlement c. The defense does not need to be informed of the brain tumor

Sample Question: Product Liability
The Plaintiff LNC has the right to research problematic defibrillators related to the client's alleged injury because of the a. FDA Medical Device Report (MDR) b. Freedom of Information Act (FOIA) c. Consumer Expectation Test d. Keogh Plan

Rationale: FOIA Request
Excerpt from Core: “……adverse effects of drugs and devices are reported in the postmarketing surveillance period……Under the FOIA, every citizen is entitled to request this information from the FDA…..LNCs may…..write to the FDA requesting information regarding ADR or MDR for a particular drug or device……….” Source: Windler, P. and Barnes, S. (2010). Pharmaceutical and Medical Device Product Liability Litigation. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles. Boca Raton, FL: CRC Press. (See excerpt on page 579.)

Toxic Tort Scenario Ben Johnson worked and lived seasonally at a mill in rural northern Wisconsin for 10 years. As a result of his work responsibilities, Mr. Johnson was in direct contact with the cleaning solvent benzene. The living and working conditions at the mill would be considered rustic since there was no running water and Ben brought a supply of drinking water each week, had no means to shower and was unable to launder his clothes.

Toxic Tort Scenario After ten years of employment, he was diagnosed with acute myelocytic leukemia. He received workers’ compensation benefits until his death eight months later. Following Mr. Johnson’s death, his family sought counsel to inquire about a potential suit against the owner of the mill.

Sample Questions: Toxic Tort
The LNC working with the plaintiff attorney should understand the mill owner cannot be sued because the Johnson case involves a. A toxic tort b. Criminal liability c. Worker’s compensation d. Product liability Answer: c. Worker’s compensation. Rationale:

Rationale: Liability of Employer
Excerpt from Core (“no fault”) “The leading principle of the workers’ compensation system is to eliminate fault as a basis of recovery for the injured worker. Under state’s workers’ compensation systems, the injured worker gives up the right to bring a tort claim against his employer, regardless of fault or negligence. In return, the worker is guaranteed medical and wage benefits by some method of insurance coverage…” Source: Hand, J. (2010). Worker’s Compensation Case Evaluation. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. (See page 484)

Rationale: Exceptions to No-Fault Rule
Excerpt from Core: “……There are few exceptions to the no-fault rule in workers’ compensation….” Source: Hand, J. (2010). Worker’s Compensation Case Evaluation. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. (See page 488)

Rationale: Exceptions / Deliberate Intent
Provides an avenue for pursuing further monetary compensation in instances where it can be proven that the employer had a deliberate intent to create an unsafe work environment (employer loses workers' compensation immunity and can be held liable for damages in a civil court action) Only a few states have this exception (e.g. WV)

Because the exposure was outside the expert retained to determine if Mr. Johnson’s exposure exceeded the permissible exposure limit (PEL) of benzene will have difficulty measuring its a. route b. duration c. frequency d. dose Answer: d. Dose Rationale: The exposure occurred outdoors, rather than in an enclosed space where the level of benzene could be measured. Since the exposure level was variable, it is difficult to estimate the dose of chemical he received.

Rationale: Difficulty Measuring Dose when Exposure Occurs Outside
Key to answer – occurred outside Important to confirm exposure exists Exposure measured by the route, duration, frequency Expert needed to confirm dose Excerpt from Core: “The most important determination to be made during the preparation of the case is the confirmation that an exposure occurred. Exposure is measured in terms of the route or means of exposure. Discovery will reveal facts as to whether the plaintiff sustained an exposure by inhalation, oral ingestion, or cutaneous absorption, including ophthalmic exposure.”

Rationale: Difficulty Measuring Dose when Exposure Occurs Outside
Source: Cannon, M. & Ridgely, E. (2010). Evaluating Toxic Tort Cases. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles. Boca Raton, FL: CRC Press. (See page 592)

To determine the permissible exposure limit (PEL) of benzene, the plaintiff LNC should contact which of these agencies? a. Society of Toxicology (SOT). b. Environmental Protection Agency (EPA). c. Centers for Disease Control and Prevention (CDC). d. Occupational Safety and Health Administration (OSHA). Answer: d. OSHA Rationale: OSHA is the governmental agency responsible for setting the standards for chemical exposures in the workplace

Rationale: OSHA sets PELs for Chemicals
Excerpt from Core: In 1989, OSHA (Occupational Safety & Health Administration) set permissible exposure limits (PELs) for nearly 500 hazardous chemicals in the US. Source: Cannon, M. & Ridgely, E. (2010). Evaluating Toxic Tort Cases. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles. Boca Raton, FL: CRC Press. (See page 594)

What document should the plaintiff LNC obtain information about safe handling of benzene to share with the attorney? a. Material Safety Data Sheet (MSDS). b. Threshold limit value (TLV). c. Recommended exposure limit (REL). d. Hazards Communication Standard (HCS). Answer: a. MSDS Rationale: A Material Safety Data Sheet (MSDS) must be developed by chemical manufacturers and importers for each hazardous chemical they produce or import and must be provided to distributors or employers with their initial shipment of the chemical and after a MSDS is updated. The MSDS includes information about the physical and health hazards, primary routes of entry, exposure limits, and precautionary measures for safe handling and use, as well as other information. Copies of the required MSDS for each hazardous chemical in the workplace must be maintained and made readily accessible during each work shift to all employees.

Rationale: MSDS & Product Labeling
Excerpt from Core: “Proper labeling and safe use guidelines are important in cases of chemical exposure. The material safety data sheet (MSDS) describes what is in a compound, any health hazards, fire hazards, use, storage, and disposal.” Source: Cannon, M. & Ridgely, E. (2010). Evaluating Toxic Tort Cases. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles. Boca Raton, FL: CRC Press. (See page 594) For more info on Benzene litigation, see page

Sample Question: Life Care Planning
In which case would a life care planner attest to being a patient advocate? a. When retained by the plaintiff b. When retained by the defense c. Always d. Never

Rationale: Life Care Planner as Advocate?
Some might think “always” but “never” is the correct answer As an expert witness, a LCP is expected to be objective & factual, regardless of hiring party Purpose of a LCP is to present facts about disability related needs and associated costs, not to advocate for patient

Rationale: Life Care Planner as Advocate?
Excerpt from Core: “The life care plan should be …….written in an objective and consistent matter, in addition to being comprehensive, based on multidisciplinary data and adaptive to change.....” Source: LaGasse, N. & McDaniel, H. (2010). The Life Care Planning Expert. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. (See page 274)

Sample Questions: Workers’ Compensation
The largest single factor affecting the value of a workers' compensation claim is the a. Size of the damages b. Strength of the medical evidence c. Degree of employer fault d. Number of prior employee claims

Rationale: Largest Factor Affecting Value of WC Claim
Excerpt from Core: “…..Since the largest single factor affecting the value of a WC claim is the strength of the medical evidence…..” Source: Hand, J. (2010). Worker’s Compensation Case Evaluation. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. (See page 482)

Sample Questions: Workers’ Compensation
The "but for the employment" principle in workers' compensation cases can be used to determine a. Liability b. Damages c. Compensability d. Duty

Rationale: “But For” Principle
Excerpt from Core: “Sometimes the use of but for the employment can guide determination of causation.” (e.g. accident occurs while running errands for employer) Source: Hand, J. (2010). Worker’s Compensation Case Evaluation. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. (See page 490)

Risk Management Scenario
Ryan Cleary, 12 years old, had an unwitnessed fall from his scooter. He was found by his mother in a dazed condition. She immediately took him to the closest Emergency Department (ED). The Cleary’s were insured by an HMO to which the hospital was not a member. The Cleary’s waited for 3 hours in the waiting room while the hospital staff tried to reach the HMO to obtain permission to treat Ryan.

Risk Management Scenario
During the wait, Ryan became increasingly restless and irritable. Eventually, he vomited and lost consciousness. He was immediately seen by the ED physician, admitted to the neurosurgery service and underwent emergency surgery to evacuate a subdural hematoma. Ryan’s post-operative course was uneventful.

Sample Questions: Risk Management
An incident report was completed and the hospital risk manager began an investigation to determine if the hospital had violated the Emergency Medical Treatment and Active labor Act (EMTALA). The risk manager believed an EMTALA violation did occur.

The Plaintiff LNC knows an electronic incident report a. Needs to be distributed to all parties involved in the event after approval by the peer review committee. b. Should be included in the medical record c. Should be available at the ED nursing team meetings for educational purposes d. Needs to be requested in a prescribed manner to become discoverable Answer: D. Needs to be requested in a prescribed manner to become discoverable. Rationale:

Rationale: Discoverability of Incident Report
Discoverability will vary by state, typically incident reports are protected by peer review statute See p. 137 – 139 (in Practices) for general info on incident reports. For discoverability of incident reports, see p. 146 – 147 (in Principles). Source: Curley, D. & Whidden, S. (2010). The LNC’s Role in Healthcare Risk Management. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. DiCecco, K. (2010). Discovery and Disclosure. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Principles. Boca Raton, FL: CRC Press

Once the EMTALA violation is confirmed, the risk manager should immediately a. Notify the hospital’s insurance claims adjuster to begin negotiations b. Inform the hospital chief executive officer and legal counsel c. Educate the ED’s medical and nursing staff to prevent future incidents. d. Begin a root cause analysis of the event. Answer: B. Inform the hospital chief executive officer and legal counsel. Rationale:

Rationale: Next Steps if EMTALA Violation is Confirmed
Question is asking about next steps for risk manager Key is the word “immediately” in the question All items may be needed eventually, but you think about what might be necessary first

Which of the following best describes the error made in the ED to form the basis of the EMTALA violation: a. Failure to aggressively obtain HMO authorization for treatment b. Failure to transport Ryan to a HMO approved hospital c. Failure to obtain a pediatric consult to assess Ryan’s symptoms. d. Failure to provide a medical screening when Ryan presented in the ED. Answer: D. Failure to provide a medical screening when Ryan presented in the ED. Rationale:

Rationale: MSE Required by EMTALA
Excerpt from Core: “EMTALA mandates that any individual who arrives at the ED seeking emergency care or is in active labor is entitled to receive a medical screening examination (MSE), within the hospital’s capability, to determine whether an emergency medical condition (EMC) exists.” Screening must occur before asking patient to produce financial forms or insurance information. Source: Lacker, C. & Rollo, K. (2010). Ambulatory Care Settings. In A. Peterson & L. Kopishke (Eds), Legal nurse consulting: Practices. Boca Raton, FL: CRC Press. (See pages 406 – 407.)

QUESTIONS??? Faculty For additional questions
Julie Dickinson – Karen Huff – For additional questions Website: or address for LNCC Certification inquiries:

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