The importance of medical records with regard to the management of a patient can never be understated. They contain details regarding patient history, clinical findings, diagnostic test results, surgeries undergone and care provided, progress notes, and medications among others.
- This documentation is significant from the point of view of evaluating the patientâ€™s medical condition, analyzing the treatment results and planning treatment procedures.
- Insurers demand proper record keeping to prove the medical necessity of services provided. Shoddy record keeping will result in unpaid claims.
- Well-organized and updated medical records are also very important with regard to any issue of alleged medical negligence. These are the most important evidences that help decide the acquittal or sentencing of the physician. Attorneys on both sides review this documentation with the support of medical review services to identify and understand the various medical facts involved.
A medical chart review company assisting a medical malpractice attorney would be looking for facts such as the following among others:
- Whether the patient agreed to undergo the procedures conducted.
- Whether the surgical notes are properly written.
- Whether drug prescriptions are legible with the name of the patient, date and the doctorâ€™s signature.
- Whether suspicious alterations have been made.
Important Considerations for Practitioners
- Given the legal importance of accurate medical documentation, practitioners must make sure that they note down all significant findings, positive and negative, normal and abnormal.
- Medical records that are properly maintained with all details of treatment provided and why those treatment decisions were made, can prove valuable in defending an allegation of substandard care. On the other hand, poor documentation will lead to questions such as why the treatment was provided or whether the treatment was actually provided.
- Physicians should never alter a medical record, even when they learn about an impending lawsuit. Alterations should not be made even if they are intended to provide more clarity to the information. If these changes are discovered, the jury will be informed of the same and the physicianâ€™s credibility will be seriously compromised. The judicial system and juries are generally respectful to the judgment and professionalism of doctors. If it is found that the doctor altered the medical records, it will surely have a negative impact with the jury losing trust in the practitionerâ€™s integrity.
To ensure that the patient medical chart does not turn into a double-edged sword in a medical malpractice lawsuit, physicians should maintain them properly as suggested above. The best practice is to make appropriate updated notes in medical records to enhance clinical care as well as successfully defend a claim, if unfortunately an adverse event occurs. It is important that the nursing and paramedical staff is also trained in the proper maintenance of medical records.