We often get questions from clients and potential clients concerning medical records that are inconsistent with their recollection of the care that was provided or physician or nursing statements at that time.
Sometimes people wonder if someone else’s medical record, lab results, or radiology report may have gotten mixed in their file. Other times, patients wonder if a doctor, nurse, or administrative staff member went back and removed or modified medical records.
Fortunately, there are a few ways to get to the bottom of such concerns.
First, most hospitals, clinics, and even physician offices use electronic medical records (EMR) these days. One of the requirements of any EMR platform is that they contain an audit trail. Audit trails are logs of all activity in the electronic medical record, including the user identity, location, date, and time that each entry, modification, or access to read the medical record occurred.
When we investigate medical malpractice cases and are suspicious about the accuracy or completion of the medical record, we use all tools available under the law to obtain the audit trail. Many courts have held that patients have a right of access to the audit trail. Having an expert analyze the audit trail in a case can be very useful.
Second, everyone experiences a fuzzy memory sometimes. It’s also possible to misunderstand a word that unfamiliar. These are reasons why think it’s important to keep a diary or notes of every healthcare visit. If you have a conversation with a physician, physician assistant (PA), or nurse practitioner (NP) about your care, treatment, blood work, laboratory results, or radiology findings, take some notes about what they say. Ask questions to ensure that you have a clear understanding of what they are trying to communicate.
One of the benefits of keeping a healthcare diary is for reference if a doctor or other provider changes makes a statement or provides an explanation that inconsistent with what you recall.
Another benefit has come up in numerous medical malpractice cases that we’ve handled where there is no relevant medical record documentation. This happens more often than you think.
We’re working on a case now where the record is entirely silent about the key 45 minutes of care in a medical malpractice case involving a hospital is infant. Multiple physicians, registered nurses, and respiratory therapists failed to document anything. If the parents of the patient hadn’t kept notes of what occurred, it would be easier for the defense to create a confusing “he said, she said” dilemma for the jury to sort out.
In another case, a middle-aged outpatient at an imaging center went into respiratory and cardiac arrest after administration of CT contrast media. He had a terrible anaphylactic reaction to the iodine-containing contrast and died within an hour. The imaging center medical records make no reference to any complication. Without contemporaneous information maintained by this patient’s wife, it would likely be impossible to figure out what happened.
If you find yourself in a situation where you’re questioning the accuracy of your medical records, contact an experienced medical malpractice lawyer to discuss your concerns and see if you have a potential case.