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Medical records, texts, and chats: The sources of physician and healthcare provider patient care documentation

Requesting any and all medical records usually isn't enough

One of the first things that medical malpractice lawyers do when starting an investigation into a new case is order all the relevant medical records.

You’d think that this would be an easy proposition. It’s not.

Quite often, our clients believe that they already have a complete set of their medical records. In reality, though, when a patient asks for their medical records, hospital release of information offices often only provide a small fraction of them, typically limited to physician notes.

At Painter Law Firm, we invariably ask for “any and all medical records.” Hospital release of information offices usually provide more comprehensive responses to attorneys. Yet, we frequently have to go back and ask hospitals to produce specific parts of the medical records that were left out. We identify what’s missing by having a legal nurse consultant review every page with an eye toward categories of documents that might be missing.

This was an issue that we confronted in a Houston case against a major hospital in the Texas Medical Center. We were investigating the circumstances surrounding a premature extubation (removal of a breathing tube) of a patient after surgery that caused a brain injury.

We immediately noticed that the hospital didn’t provide the code sheet, oxygen saturation data, or respiratory therapy notes in response to our request for “any and all medical records.” After the hospital looked harder, they located what we needed and produced these key documents.

That case would’ve turned out differently if our office didn’t know what to look for. Indeed, the ability to recognize an incomplete medical record is one of the many benefits of hiring an attorney with extensive experience in handling medical malpractice cases.

With the advent of electronic medical records and other digital technology, there’s another emerging challenge in capturing health care documentation. Physicians and health care providers are using tools to communicate with each other about patient care that aren’t part of the medical records.

Text messages

We’re currently working on a case in the Dallas area where a physician assistant (PA) testified at deposition that her supervising spine surgeon only wanted communications through text messages. She explained that they use regular iPhone text messaging, and that the spine surgeon preferred that over having a conversation by phone.

In that case, the PA evaluated a post-surgical patient who couldn’t feel his extremities. This was a clear sign of a neurological emergency, but after texting back and forth with the spine surgeon, nothing happened until the next day. It will be interesting to see what the spine surgeon says in his deposition.

Messaging apps

The Texas Medical Association offers its members free access to a secure physician to physician messaging app called DocbookMD. Hundreds of thousands of physicians nationwide use this app to send HIPAA-compliant messages to each other about patients. In the past, these communications may have been in the forms of letters faxed between physician officers, which ended up in patient medical records. Or, perhaps phone calls that were documented.

With messaging apps, sometimes the only documentation stays within the app. Thus, it’s not produced when there’s a request for medical records.

Electronic medical record (EMR) secure chats

Virtually every hospital and physician office in America uses electronic medical record (EMR) software. Epic is one of the largest EMR vendors, their software offers a secure chat feature.

Physicians and healthcare providers can use secure chat to communicate about patients, but the chats do not save to a patient’s medical record and are deleted after 14 days.

 

While a chat may be a useful tool, it’s not a suitable substitute for direct communications. I read an interesting thread on Twitter that started with a physician assistant’s (PA) comment that “If you sent an EPIC chat, you did not ‘page’ the team and should not chart that.”

This Tweet response provided an interesting insight to the problem, “We’re about to switch to Epic without our lab, and have been using Epic secure chat more and more. Often times the number listed for the provider’s office number, same number use to schedule appointments. I’ll try to find a patient, find their nurse, find a provider. . . . I would LOVE to page providers directly, but our system does NOT make it easy to find y’all sometimes.”

A registered nurse added her Tweet that, “it’s all over the board, most want to be paid first but there are whole teams that have secure chat listed as a first contact preference method.”

The PA who posted the original Tweet and concern explained, “I get that – some people prefer it I just get a bit flustered when I come back to work and I have 5 unopened chats and several charted notes saying they paged me with no response.”

Litigation issues

One of the significant issues that we investigate in medical malpractice cases is whether there was timely, appropriate communication among health care team members. Did the laboratory inform the clinical team of critical lab values that require urgent medical attention? Did the radiologist inform the physician of critical findings? Did the nursing staff inform a physician, physician assistant, or nurse practitioner, of important clinical changes?

Documentation in the medical record provides important evidence of communications. As we take depositions of physicians and other healthcare providers and nurses, we will be certain to ask about the specific way patient information was communicated, and how they know that it was timely received.

If you’ve been seriously injured because of poor hospital or medical care in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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