Gynecology Negligence Claims and the Significance of Medical Documentation

by | Published on Jan 23, 2023 | Medical Record Review

Gynecology medical negligence claims and the need for comprehensive medical record review arise when a patient’s medical treatment did not meet the required standards and caused her harm. Clinical negligence can arise when the gynecologist fails to make an accurate diagnosis or when the treatment provided causes further injury to the patient.

Common Instances for Gynecology Medical Negligence

Here are some of the common mistakes that lead to gynecology medical malpractice lawsuits.

  • Failure to diagnose or making a wrong diagnosis
  • Causing harm to other organs during surgery
  • Providing unnecessary surgical treatments such as hysterectomy
  • Therapy failure
  • Errors in the administration of therapy
  • Lack of medical documentation recording various treatment instructions given, and patient and family education
  • Not observing compliance
  • Not providing informed consent for high-risk gynecologic/obstetric procedures

Significance of Accurate Documentation and Medical Records Analysis

Poor documentation can prove extremely risky for gynecologists, which is why they must take great care to document everything related to diagnoses, causes, treatment provided and patient prognosis. Apart from documenting, the information and education must be conveyed to the patient and his/her family also. Gynecology documentation and the medical evidence obtained via medical records analysis can prove to be the best defense for the gynecologist and help answer questions that may be asked even months or years after the adverse medical event.

  • The patient’s particular health issue(s), instructions provided regarding therapy, medical procedures/actions, and informed consent from the patient must be clearly and completely documented in the medical record. If the documentation is to be accepted in a court of law, it has to be accurate and complete.
  • The medical records must be kept for an appropriate period of time so that if some lawsuit is filed, there is documentation to support the gynecologist and the healthcare facility.
  • If there are two or more physicians attending a patient, the documentation they make must be consistent without any contradictions because it could lead to complications in court.
  • There should be clearly documented SOP (Standard Operating Procedures) or MSS (Medical Service Standards). Typically, courts look at whether the treatment has been provided in keeping with the guidelines provided by the healthcare facility.
  • In case further treatment or investigation cannot be carried out for a high-risk patient at the healthcare facility, timely referrals must be made and documented. If this is not done, medico-legal problems can arise.
  • Another important part of documentation is that of the risk management strategies adopted. Any risk management strategy involves healthcare providers, technicians, lawyers, health insurers, hospital administrators and others.

Complete Medical Documentation Provides the Right Evidence

To bring a medical malpractice case against a gynecologist or obstetrician, three conditions should exist, and which can be evinced by the medical records. These three conditions are:

  • The provider had an obligation to treat the patient
  • There has been a breach of duty of care by the doctor
  • The injury or damage, whether physical or emotional, caused to the patient can be traced to that breach of duty of car by the doctor.

Here are the documents that are important in any medical negligence case:

  • Detailed statements including appointment dates, healthcare providers and other hospital staff who attended to the patient, and how the events emerged
  • Results of medical tests and scans
  • Witness statements
  • Evidence of financial losses incurred by the patient
  • Medical report from an experienced medical expert
  • Relevant photographs

When the healthcare provider, practice or facility has taken all necessary precautions to prevent injury to the patient and still an injury occurs, it does not amount to medical negligence because there is no breach of duty. So, comprehensive and accurate documentation about the situation or event, medical instructions, procedures and actions, informed consent and safe storage of medical records are important for establishing the various actions that were carried out during treatment. The SOP or MSS are also significant in the event of a medical negligence case because it can be used as a standard reference for the treatments provided and other actions taken by the treating physician.

Why Document as Much as Possible?

Accurate, clear, and timely patient records can reduce the legal hassles associated with a medical negligence lawsuit filed against a provider or facility. One of the most important documents is the informed consent for treatment from the patient or her family because it would outline all the risks of any procedure that the doctor is going to provide the patient. A chart review by medical review experts would highlight such informed consent. Many medical malpractice cases are associated with a known complication of a treatment. However, people often mistakenly think that it is caused by the doctor’s fault. That is where the consent form becomes significant. The defense attorney can produce proper consent forms to a jury and prove that the patient agreed to undergo the procedure even after being informed of possible complications.

Another important consideration is that many cases take years to reach a courtroom by which time memories regarding the adverse gynecology medical event may have somewhat faded. This concern need not be there when the documentation is concurrent and perfect. A detailed medical chart review can easily recount the various medical events and demonstrate whether the physician provided good care. The plaintiff attorney will be looking for what is documented in the medical record, and if something is not documented, it would be considered not done.

As a medical record review company assisting medical malpractice attorneys, we know that the attorney and his legal team will compile all the necessary evidence to proceed with the case. Important among this evidence are the medical notes from the staff who treated the patient, and reports from independent medical experts called in to review the patient’s condition. On the part of the medical providers, the best way to prevent medical negligence lawsuits is by practicing evidence-based medicine, with excellent medical documentation and taking all necessary precautions. If a lawsuit arises, comprehensive documentation of the medical care provided to the patient is the best defense.

Disclaimer: The content in this blog is sourced from various reliable internet resources, and is meant for informative purposes only. For a professional opinion in this regard, contact an experienced medical negligence attorney.

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