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Medical Records in Litigation – Case of SCAE (Serious Clinical Adverse Event)

Medical records play a significant role in litigation involving medical malpractice, personal injury and Worker’s Compensation claims. Attorneys handling such cases have the primary responsibility of reviewing the relevant medical records. These are the only tangible and objective evidence the attorney has that throws light on the patient’s condition and the treatment provided. Thus medical record review becomes the most important process when it comes to medical litigation. The plaintiff’s attorney would naturally be looking for pointers to negligence on the part of the provider and this slackness may be inferred from reported as well as unreported events. In cases where the plaintiff’s attorney succeeds in casting doubt on the credibility of the medical records, service providers stand to lose the case as well as their reputation.

It is not difficult therefore to grasp the immense significance of well-maintained medical records. Physicians cautious to maintain their good name just cannot afford to have medical records that are illegible, partial and shabbily kept. Inept record keeping is something courts and jury are not likely to excuse. Physicians need to know exactly how to document and maintain the medical records of their patients.

Be Prepared for Any SCAE

Take the case of an SCAE. An SCAE (Serious Clinical Adverse Event) can occur in the wake of system failures, known risk of the treatment or procedure provided to the patient, human error, and iatrogenic injuries among other causes. In the event of a medical error occurring, physicians and associated team members must know how and when to reveal the information. There are certain legal and regulatory considerations involved in disclosing a SCAE. The American Health Lawyers Association has released a helpful checklist that will serve as a guide to healthcare professionals. The checklist classifies these considerations into:

  • Pre-disclosure considerations
  • Mandatory disclosures
  • Disclosure to patient/patient’s family
  • Voluntary disclosures to accrediting bodies, media or other third parties

This checklist was drafted by Elisabeth Belmont, corporate counsel for MaineHealth, a hospital system based in Portland. According to her, it will help providers to implement policies that can address such events before they occur. They can ensure that their staff and relevant policies are “in alignment on such disclosures prior to the occurrence of a SCAE.” This checklist is a serious reminder to physicians and their team members to maintain accurate records that relate to medical errors. These medical records may be requested by professional liability insurance carriers as well as state regulatory agencies.

The Medical Record Review Firm – a Strong Shoulder to Lean on

Sensitive medical records are best maintained by a professional medical record review company that can take over the complete responsibility of organizing the numerous medical records. These firms serve physicians, attorneys, and insurance companies among other clients. With efficient medical record organization, medical history and summary, and medical case chronology services they ensure that all medical records entrusted are perfectly organized for a clear understanding of the medical events related to a patient.

About Rajeev Rajagopal

Rajeev Rajagopal

Manages the day-to-day operations of MOS from NY. With an interest in information technology, I have guided MOS to extensive use of digital technology and the internet that benefits MOS as well as MOS clients.