Preventable Infections, Medical Malpractice and the Use of Medical Records

Medical Records

Preventable infections are a common injury that leads to medical malpractice lawsuits and consequent medical records analysis to extract the important medical evidence. Patients who seek medical treatment sometimes develop preventable infections due to medical negligence and may be eligible to recover compensation for medical malpractice. The Centers for Disease Control and Prevention (CDS) puts this number at around 1.7 million patients on an annual basis.

Most Common Hospital Acquired  Infections (HAI)

  • Pneumonia
  • MRSA (Methicillin-resistant Staphylococcus aureus)
  • Urinary tract infections
  • Sepsis
  • Surgical site infections
  • Clostridium difficile and other gastrointestinal infections
  • Central-line associated bloodstream infections
  • Influenza
  • Hepatitis
  • Norovirus
  • Skin infections
  • Streptococcal
  • Urinary tract infections
  • Gastroenteritis
  • MRSA (Methicillin-resistant staphylococcus aureus)
  • Covid-19
  • CDIs or clostridium difficile infections
  • Soft tissue infections

These infections can be caused by a natural reaction to a surgical procedure or by unsanitary behavior on the part of the providers. If the provider is to be held responsible for the plaintiff’s injury, the following aspects must be proved: that there was a doctor-patient fellowship, the healthcare provider breached his/her professional duty of care, actual and immediate causation, and damages. The breach of the professional duty of care must be proven to be the actual cause of the infection and also that the infection would not have occurred if the provider had not failed to abide by the professional duty of care.

How Significant Are Medical Records?

Medical records provide clear documentary evidence of a patient’s healthcare information and are therefore very important when reviewing hospital acquired infection cases. In medical malpractice cases, the attorney obtains the client’s medical records and assesses whether the case has legal merit.

It is through the medical records and medical chart review that you get to understand the type of infection, the treatments provided, results of various lab assays and other tests and so on. If a patient is admitted to the emergency room with an attack of meningitis, sepsis or other serious infections, there should be related medical records and documentation to support the claim. Typically, the opinion of a second or third doctor is valuable because it helps to determine the extent of the infection and document the symptoms appropriately for legal purposes. In this regard, relevant medical records would include those related to lab tests, biopsies, X-rays and other imaging studies.

Whether it is a viral or a bacterial infection, the medical records would contain all symptoms exhibited by the patient when these are accurately recorded. If such details are missing from the records, it is a red flag suggesting possible malpractice on the part of the provider. Apart from this, you get a clear idea of the diagnosis, the treatment plan, attending physicians, treatments provided, outcomes, and prognosis. Among the steps involved in a medical malpractice case are the following:

  • Review of the medical records by an attorney or by using medical review solutions provided by a professional medical review firm.
  • Consultation with a medical review expert to review the inferences.
  • Signing of the Affidavit of Merit by the medical review expert before filing the case, if medical malpractice is identified.

Medical charts or records provide all the information regarding a patient such as history, diagnostic findings, test results, care before and after surgery, progress notes and various medications prescribed. Medical records are significant because accurate medical documentation will provide the required support the doctor needs regarding the appropriateness of treatment.

Medical Review Services Are Advantageous for Attorneys

Given the importance of medical records and their use in medical malpractice cases, let us consider how attorneys can make the best use of the medical information available. There is no doubt that both plaintiff and defense attorneys and their legal teams can benefit from the assistance of medical review companies. The confidential healthcare information contained in the medical records can be extracted via medical records analysis. Legal professionals can efficiently address challenges such as:

  • Large-volume medical records
  • Unorganized and confusing medical documentation
  • Identifying and removing irrelevant medical records
  • Complex medical terms and jargon
  • Handwritten medical documents

 

Read our blog 10 Challenges Attorneys Say Are Involved in Medical Record Review

The comprehensive review of the medical chart will help determine whether there has been a breach in the expected standard of care and consequent injury to the patient. It also reveals the link between the breach in care and the injury. Professional reviewers analyze the medical records for each area of liability and potential liability. Moreover, it is through the review that you can determine whether other medical specialists have to be consulted for additional review and expert opinion. The medical record chronology prepared will provide the attorney a clear understanding of the timeline of medical encounters.

We have discussed the various preventable infections, many of them hospital acquired, that can lead to medical malpractice lawsuits and considerable distress to all parties involved. Accurate and complete medical records showing adherence to evidence-based best practices for the patient are the best defense for medical professionals. Importantly, such records are invaluable when it comes to monitoring patients and promoting infection prevention measures.

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