Medical records are vital to a personal injury attorney representing an injured person or the defense attorney representing the physician or other care provider. These valuable documents provide a complete picture of the nature and extent of the injuries, the amount of pain and suffering and so on, via a comprehensive medical record review. You need to obtain copies of all relevant current as well as earlier medical records if you are to represent your client adequately. This is the age of electronic medical records (EMR) with many hospitals, doctors, clinics and other healthcare providers using EMRs to provide health services. The electronic health record is expected to provide all healthcare information regarding a patient’s medical history, diagnoses, current and previous medications, allergies and immunization records, imaging records, lab results and reports and other details. It assembles information from current as well as past care providers, emergency departments, pharmacies, clinics, medical labs and imaging facilities. In spite of its apparent advantages, the electronic medical record can also harm patients if there are errors in medical record reporting.
So what are the possible medical record reporting errors?
- Accidentally clicking on the wrong choice in the EMR system can lead to the wrong prescription being printed.
- When the physician or other clinicians do not check fields where wrong information may have been entered.
- Errors perpetrated by accidentally cutting and pasting information from one spot to another.
- Errors occurring from the EMR failing to alert the physician of medication allergies.
- Issues arising from the physician not being able to focus on the patient when forced to look at the computer. This may lead to possible missed or misinterpreted information.
- Medical mistakes arising from the doctor not adequately reviewing the EHR information or discussing the details with the patient.
Injuries caused in a medical setting, those caused by medical record errors and those resulting from a doctor’s negligent diagnosis/treatment are litigated under medical malpractice. In such cases, medical record review for attorneys would focus on locating the erratic entries and signs of negligence in the medical records. The electronic medical information may be inaccurate or incomplete because of wrong information provided by the patient, or erroneous documentation on the part of the doctor, nurse or other medical staff. Whatever be the reason, errors in the EMR would put the care provider at the risk of medical malpractice. In most cases, medical records are the main documentation that would be considered as evidence.
Personal injury attorneys handling medical malpractice cases would be dealing with diverse areas such as prescription errors, surgical errors, emergency medicine, anesthesia errors, hospital errors, misdiagnosis, and so on. All these instances would require medical record review to obtain a clear medical chronology and summary that are important for defense as well as plaintiff attorneys.
The electronic medical record has the capabilities to prevent malpractice provided the documentation is accurate. To ensure error-free entries, physicians must be educated and trained in the use of these systems; they must have diligence and become familiar with the complexities of their EMR systems.