When we meet with a new medical malpractice client at Painter Law Firm, we do a thorough interview to make sure we understand exactly what happened during the relevant healthcare that led to serious injury.
The next step is ordering all of the relevant medical records for a careful review. It’s not uncommon for our legal nurses to find discrepancies between the client recollection of events and what’s recorded in the medical records.
Inputting errors
Oftentimes, the differences are because of user error from typing information into the electronic medical records. This frequently happens when doctors or nurses copy and paste text from prior visits, assessments, or evaluations that either they or other providers performed.
Sometimes these copy and paste errors are easy to spot. We’ve seen cases where the first doctor or nurse who saw a hospitalized patient noted the wrong race, sex, or age, and that got repeated over and over again in the medical records.
Documentation mistakes
On other occasions, it’s clear that a healthcare provider made a mistake about a patient’s past medical history, noting a condition that the patient never had.
We’ve also seen multiple cases where the medical records reflect that the patient had the exact same pulse, blood pressure, and respiration rate every time they were documented throughout a 12-hour shift. The odds of that are simply unfathomable.
These types of errors can have dangerous consequences for the patient because they can alter the course of treatment. The standard of care requires providers, doctors, and nurses to perform and accurately document their own independent assessment of each and every patient encounter.
Falsified records
The final type of medical records discrepancy that we see from time to time is falsified or fake medical records. These are the ones that are most hurtful and infuriating to patients and family members who know for certain that the entries are absolutely false.
Sometimes falsified medical record entries are easy to spot, and other times they are more subtle.
For example, it’s suspicious if the patient experienced a rare complication from a surgery or procedure and a physician note contains a thorough narrative of how that one risk was discussed in detail before obtaining informed consent.
We also look for self-serving statements made by healthcare providers and indicators that notes were added after the fact.
How these factors impact a case
The biggest challenge for plaintiffs whose medical records are substantially inaccurate is getting a medical expert on board to support your case. In order to pursue a Texas medical malpractice case, Texas tort reform laws require a written report from at least one physician expert that supports the plaintiff’s case.
Most medical experts understandably feel that the medical records are typically the safe harbor in which they can base their opinions. An additional hurdle is that Texas law also imposes a discovery stay that prevents taking depositions and conducting written discovery until the plaintiff produces the written expert report.
Thus, in situations where the medical records are questionable, we often look to medical records from prior or subsequent healthcare providers to illuminate the truth of what really happened. In some situations, we offer to have the medical expert conduct a patient history interview of the plaintiff.
Once the preliminary expert report is obtained, other discovery tools become available to investigate suspicious medical records. These include taking the depositions of healthcare providers and obtaining medical record audit trails that specify the user, date, and time for every entry or revision of the medical records.
If you’ve been seriously injured and suspect that poor medical care may be at issue, it’s in your best interest to hire a top-rated experienced Houston, Texas medical malpractice attorney as soon as possible. Issues like the integrity of medical records take time to investigate.
