Medical record keeping has a storied history. Jokes about handwriting aside, medical records have as often been used as a definitive defense as they have been a smoking gun.
Doctors fight the duality of record keeping as it applies to medical malpractice cases. They need accurate records to enable proper treatment, but they also work in a time-crunch environment where its not always obvious what is in records.
This leads to a series of post-hoc additions to records. Some of these illuminated while others obfuscate. In the end, the issue of record keeping plays a crucial component in malpractice law.
Records as Prevention
The first, and most important use of medical records, is to prevent harm and ensure a stand of care. Records indicate the steps taken by medical professionals, when, and how much. Each of these pieces of information can be weighed against best-practices.
Typically, a doctor wants their records to be accurate without being a burden. Notations for procedures, check-ups, medication dosage and so can be coded or abbreviated for time. These time saving measures can lead to confusion with new and under-trained staff.
Even when records are well kept and accurate, mistakes can still occur. In this case, the records may not indicate how or why a mistake happened. One third of all medical mistakes are shown to be due to improper communication.
Record keeping shows an echo of communication but does not represent the whole of an interaction.
Records as Deterrent
The second use of records is to provide a defense against potential civil cases. A hospital can provide records to show how care was undertaken and the steps followed. The records detail every interaction and procedure.
The simple existence of the records can be enough to leave some unwilling to file a suit because they feel the records will hold up to scrutiny.
Some elements charted can become potential problems for a doctor. Studious and comprehensive record keeping mentions all information surrounding a decision. This can open the door for some elements to be seen as previously known issues. Essentially, a doctor can face a malpractice suit for what they pay attention to as much as what they don’t.
While records serve to help treatment and can be used as evidence for or against a doctor or institution, a lack of records is a bigger problem. Record keeping needs to be complete to be workable.
Missing records includes both the total loss of a patient file and the loss of individual pages. When a page is missing, it can be an innocent mistake of file keeping or a cover up.
It is the responsibility of the hospital or medical facility to maintain record collection and storage protocols. Records need to be accessible and recoverable against loss as well.
Medical records provide help and hindrances to medical malpractice cases. They are confusing and often time-consuming documents to procure and investigate. If you have been injured and suspect medical malpractice, you need a dedicated team to sort through the obstacles for you. To get to the bottom of your malpractice issues, contact us today. We’re here to help.