Importance of the Medical Record in Medical Malpractice The medical record is the patient’s other self. Patient charts document the quality of patient care. Since memories fade, medical records constitute extremely important evidence in a lawsuit
Importance of the Medical Record in Medical Malpractice
The medical record is the patient’s other self. Patient charts document the quality of patient care. Since memories fade, medical records constitute extremely important evidence in a lawsuit.
- The chart serves to trigger a health care provider’s memories of a particular case.
- A patient’s lawyer uses the medical record to investigate the patient’s allegations and decide whether a complaint has merit.
- The court usually rely on the chart as the authoritative account of what transpired. Which can be helped or harmed by what is or is not included in your patients’ medical records. Notes by non-physician health professionals are important; should be read with care.
Good charts are:
- Comprehensive
- Timely
- Legible
- Objective
- Unaltered
- Internally consistent
Good charts include (but are not limited to):
- Medical evaluations of the patient
- Consideration of appropriate diagnoses
- Formulation of treatment plans
- Evidence of diagnostic testing and their interpretation
- Notification of test results to the primary physician
- Documentation of informed consent to procedures and treatments that involve risks
Common Medical Record Mistakes:
- Inadequate: They lack progress notes, consultation reports, justifications for continued hospital stays, reasons for undertaking or modifying treatment, data and judgments that lead to admission decisions, conspicuous notes about patient allergies (notes that known or suspected allergies were investigated), dates and times for all entries or records of telephone conversations (including prescriptions, refills, advice and follow-up plans). Records of phone conversations and telephone messages should be retained.
- Unsigned or untimely: If transcribed reports are unsigned or uninitiated, uncorrected or obviously unread, juries may react negatively, reasoning that substandard charts reflect substandard care. If a report is delayed, and the patient outcome is unfavorable, that patient’s attorney will argue that the report was slanted to justify the physician’s judgments and actions. Late entries are accepted as long as they are labeled as late entries and the delay is justified by the circumstances. The note should not appear to be self-serving.
- Illegible or haphazard: Unreadable records may adversely affect care, and they hinder attempts to demonstrate that a reasonable course of treatment was identified and followed. Juries may infer haphazard care from scribbled entries, unintelligible handwriting or non-standard abbreviations. Misplaced decimals and/or uncertain spellings of drugs with names similar to other drugs represent significant hazards.
- Critical or subjective: The medical record is not the place to criticize colleagues or the institution, to place blame, or to suggest fault is with words like “inadvertently” or “accidentally”. Gratuitous comments or inappropriate patient characterizations should be avoided. Stick to the facts. If you record a patient’s or family member’s opinion of an incident, place their words in quotation marks and attribute the comment to them so it does not appear to be your opinion.
- Altered or missing: Even innocent deletions, white-outs or obliterations are unaccepted and may be constructed by juries as a “cover up”. Correct errors by putting a single line through erroneous information, and write “error”, the date and your initials above that section.
It is worth noting that “chart wars” should not be conducted with colleagues who have differing opinions about the diagnostic or therapeutic aspects of care. Instead, speak with your colleagues, come to a mutually agreeable understanding, and let the chart reflect that understanding.
Retain adult records a minimum of 10 years from the last visit. Records of minors should be retained until the minor is 24 years old. Records of mentally disabled persons should be kept 10 years after their death or 3 years past the date they are judged no longer mentally disabled. Deceased patients’ records should be kept 10 years following death. X-rays should not be destroyed until 4 years from the date of the last visit. Any willful violation of the law regarding medical records, including their destruction, falsification or unauthorized release may result in civil or criminal liability to you.
Mohamed Mahmoud Al Marzooqi law firm
Attorney / Mohamed Al Marzooqi
Mohamed Al Marzooqi advocates & Consultancy
Lawyer in Abu Dhabi, Dubai – UAE
