Medical Records and Their Legal Significance

by | Published on Jul 27, 2016 | Medical Record Review

Medical records document the services/treatments provided to a patient as well as the outcomes. In a medico-legal context, medical records reveal professional integrity and demonstrate what the healthcare provider did. Given the significance of medical records during medical records review in both medical and legal contexts and the fact that they come under intense scrutiny, it is important that they are accurate, sensitive and well maintained. Medical record review for attorneys handling medical malpractice cases also focus on inconsistencies and careless entries that put the healthcare provider at risk of being negligent in patient care. Defense counsel for medical professionals always emphasize the need for maintaining clear, accurate and up-to-date medical records.

The Good Medical Record Advantage

By and large, the quality of record keeping contributes a great deal as regards the physician’s success in a medical negligence case. Every notation in the medical chart must be carefully made because subtle differences between the intended meanings and the actual meaning reflected could create problems, with the defense counsel finding it difficult to convince a jury about his/her client’s innocence. So how is a thorough, accurate medical record advantageous to the medical professional?

  • It provides proof that the healthcare provider performed appropriate actions at the particular time. In a court, a good medical record is the best testimony for the level of care provided. By looking at the medical records the jury can understand what actually took place during the medical encounter.
  • If the record entries are made at the right times, they become legitimate legal documents. These entries should be accurate right from the moment of the patient’s first visit. During this visit, all prior medical records need to be obtained to study the patient’s medical history. If any error is made on this occasion, mistakes will continue to occur in the entries throughout the treatment.

Avoiding Documentation Pitfalls

  • Ambiguity or lack of clarity: The medical records have to be clear so that there is no confusion regarding the entries.
  • Failing to document each action taken: It is vital to record the action taken once a problem is identified and recorded.
  • Failing to record drugs administered
  • Not obtaining informed consent of the patient: If the informed consent interview is not documented, it would raise doubts whether the patient was made aware of the situation and agreed to undergo the treatment. An informed consent must list all the different treatment options along with the risks involved. It must be signed by the patient, a witness as well as the physician.
  • Failing to document any disparity in diagnosis: Only if a good record of differential diagnoses is kept, the physician can prove that such and such options were considered, and why other options were dismissed.
  • Maintaining inaccurate records: Instances such as recording treatment that was never given can be very risky.
  • Not defining important terms/conditions in a contract
  • Failing to record follow-up care: Juries expect physicians to be responsible and give extra importance to patient calls, complaints, test results etc. So if important aspects such as follow-up care are not recorded it can reflect badly on the physician. All complaints of patients as well as follow-up actions taken by the provider must be carefully recorded to avoid antagonizing the jury.
  • Not maintaining detailed notes taken during the procedure and treatment: If the physician makes detailed notes, the jury will consider that as signifying conscientious treatment and take that into consideration when evaluating a case. Such notes also indicate that the procedure was done properly and the patient was provided with outstanding care, even though the outcome was unfortunately adverse.
  • Lack of an accurate discharge summary: The discharge summary should contain all details regarding the condition of the patient on discharge, follow-up actions needed, information regarding medications, test results, and concerns if any. The discharge form must be signed by both patient and physician.
  • Failing to document a patient’s refusal of care or non-compliance: If this is not clearly noted, it will be difficult to prove to the jury that the patient, not the physician, was responsible for the unfavorable results.

When it comes to medical records review in medical litigation, good record keeping practices can work in favor of the medical professional, and prove to the jury that the services rendered were appropriate and timely.

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