Poor Record Keeping
Why is keeping medical records important?
Medical records are a legal document that describes and explains the care delivered. We are now entered into an age of electronic records where there is little opportunity for the surgeon to write a note on paper. This can lead to some difficulty in explaining the thought process behind dealing with the medical situation. Sometimes the operative reports are boilerplate and not individualized to the case.
I had a case recently where the patient was paralyzed after a spine procedure, but the boilerplate operative report stated that there were no complications. In another case I had recently, the entire medical chart had no reference to the fact that the radioactive material that was supposed to be injected into a vein wound up in the tissues of the arm.
When medical records are missing, a spoliation motion can be made where the court will rule that the jury must consider certain facts in favor of the plaintiff as concerns the missing records and its subject matter.
Other examples of poor record keeping
Then there is the matter of alteration of medical records. Believe it or not, this happens when lawsuits are possible. It is of course illegal and unethical, but it occurs.
Another example of poor medical record keeping is the dictation of an operative report or a discharge summary some time after the event not within the required period of time to dictate the report. The delay will lead to the impression that the doctor knew what happened before he dictated the record such that his credibility is called into question.