Poor Record Keeping and Medical Malpractice – They’re Connected

by | Published on Jul 20, 2022 | Medical Record Review

Medical records are important medico-legal documents that must be efficiently managed to avoid legal complications. It is helpful to rely upon medical record review companies to accurately compile vital information about the health, medical history, clinical findings, diagnostic notes, and medications administered to the patient among other crucial details. Any error while preparing a medical chart or record is the ground for a medical malpractice claim. This can result in legal action against the healthcare providers. Read further to know how poor record keeping culminates in medical malpractice claims.

Why is Proper Documentation of Medical Records Important?

In medical malpractice litigation, medical records serve as the basic legal document. If the medical records are well-organized, well-written, and well-formatted, they can be the best defense for the healthcare provider. A poorly kept, erroneous, or disorganized medical record is proof of medical negligence on the part of the healthcare provider. In addition, it is clear proof of substandard care.

A medical malpractice lawsuit is developed around the medical record, which is the only objective record that gives a detailed explanation of the patient’s condition and the care provided. Injuries are the evidence produced by the patient in court. However, healthcare providers have only medical records to refute the allegations.

Medical record inaccuracies can result in a medical malpractice claim

Apart from negligence arising from performing surgery, evaluating and diagnosing a patient, inaccurate records in a patient’s chart can be the cause of medical malpractice lawsuits. Below given are some of the common mistakes seen on medical records:

  • Entering incorrect symptoms

Incorrect recording of a patient’s symptoms or disregarding the conditions initially outlined by the patient can lead easily to a missed or failed diagnosis. The error can prove to be fatal depending upon the degree of severity of the health condition of the patient.

  • Recording inaccurate medical condition

Due to the complex medical jargon, misspellings can happen while entering the medical condition of the patient. This is considered a serious error as the patient is being unknowingly denied the proper treatment he/she deserves. Even mixing up a single term in the medical chart can lead to irreversible damage to the patient.

  • Errors in treatment history

The patient’s treatment history is crucial as it gives details about a chronic or debilitating illness. This is a narrative of the medications that work for the patient and those that don’t work. Poor documentation of the treatment history can lead to ineffective treatment strategy which ultimately aggravates the health condition of the patient.

  • Treating the wrong patient

A communication error can result in the health provider mixing up two patients. The two patients are vulnerable to complications, especially if the medication administered has an allergic reaction in the patient.

  • Medical history that is incomplete

Improper recording of medical history, evaluations, diagnoses, treatment plans, or recovery plans makes the medical records incomplete. This can hamper future treatments and could result in complications.

If healthcare providers have no access to accurate medical records, they would find it difficult to diagnose and treat their patients. Patients can file medical malpractice claims depending upon the circumstances surrounding the inaccurate and poor keeping of medical records. Medical record review for medical malpractice claims can ensure that the medical records are compiled and managed efficiently.

Medical Records Can Sometimes Serve As the Sole Evidence in Medical Malpractice Claims

A medical record is a breathing legal document. It can speak of the merits of the case and the exact nature of the injuries inflicted on the patient. These records are a deciding factor in proving whether the applicable standard of care was met by the healthcare provider.

There have been past instances of medical malpractice cases wherein the provider’s negligence was proven by poor, incomplete, or absent documentation of medical records.

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