Our medical malpractice clients are often surprised at what they read in their own medical records. It’s pretty common for us to hear that key information is missing, other things are inaccurate, and some things that are documented never happened at all.
A recent closed claim study by a major medical malpractice insurance carrier found that medical record documentation issues play a role in about 20% of claims. The study broke down the medical records problems into three categories: (1) insufficient/lack of documentation; (2) content decisions; and (3) mechanics.
Insufficient/lack of documentation
This, by far, is the biggest problem in medical record documentation. Here are some examples:
• Poor details. This involves leaving out critical information such as the patient problem list, medication lists, lab results, radiology results, consultations or referrals with other specialists, and signatures.
• Poor explanation, including providing no context for a treatment plan or decisions.
• Absent details about patient encounters. In general, physicians and providers are expected to write a note about their findings after seeing the patient.
• Zero documentation about a physician or provider’s involvement in the patient’s care.
• Notes about following up with a patient for necessary tests or care.
Texas Medical Board Rule 165.1 is clear regarding the requirements for physician documentation of an adequate medical record, which must be complete, contemporaneous, and legible. At a minimum, documentation of each encounter should include:
• The reason for the encounter in relevant history, physical examination findings, and prior diagnostic test results.
• An assessment, clinical impression, or diagnosis.
• A plan of care, including a discharge plan, if applicable and appropriate.
• The date and legible identity of the observer.
• Past and present diagnoses.
• The rationale for and results of diagnostic and other ancillary services.
• The patient’s progress, including response to treatment, change in diagnosis, and any non-compliance.
• Relevant risk factors.
When reviewing a potential medical malpractice case, we look carefully at the medical record documentation. Sometimes, medical records are clear and thorough. Other times, there are surprising gaps.
In a case we’re currently handling involving care in a Houston-area hospital emergency department, the attending trauma surgeon made no documentation whatsoever. He initially contended that he never saw the Level 2 trauma patient at all, even though his name was all over the nursing notes, indicating that he had been present. A resident trainee physician from the trauma service testified that she had been told not to make any documentation at all regarding patient encounters in the emergency room, unless the patient was admitted to the hospital.
This type of shoddy medical records documentation clearly violates the standard of care and does not comply with Texas Medical Board.
Content decisions
This category of medical record problems involves inconsistent, altered, and inaccurate documentation.
We frequently encounter documentation in medical records that is inconsistent among physicians and nurses who saw the patient at the same time. In one case, an emergency physician documented that the patient was stable and ready for discharge. Moments later, a registered nurse noted that the patient had continued weakness and “MD aware.” Unfortunately, there was no nursing advocacy or any evidence that the physician re-examined the patient. Thus, the patient was discharged with an undiagnosed spinal cord injury.
Now that most medical records are electronic, we use the litigation discovery process to obtain an audit trail, when we have concerns that there have been alterations to the medical record. Under federal law, electronic medical record systems must record the creation, revision, and deletions of any documentation.
We are currently working on a case where a patient went into cardiopulmonary arrest and developed a profound brain injury. The bedside nurse started a note, saved it, and then revised it the next day. We are using audit trail discovery to obtain the text of the original note.
Inaccurate information is easily repeated and relied on in electronic medical records. These are cut and paste errors. It’s not uncommon to see medical records repeatedly state an incorrect birthdate or gender for a patient. If a doctor, physician’s assistant, nurse practitioner, or registered nurse records something incorrect information in the chart, it can get recycled over and over, in error.
In another case, we represent a man who had a stroke that wasn't timely diagnosed in an emergency room. The medical records are sparse. The little documentation that exists is largely wrong. Fortunately, his wife sent real-time text messages to a family remember that provides an accurate picture of what was going on at the time.
Mechanics
This category includes documentation mistakes caused by non-standard abbreviations and illegible text. Fortunately, electronic medical record documentation has removed most of the challenges posed by poor handwriting.
When non-standard abbreviations are used, though, it can result in medication or dosage errors that could cause serious patient injury.
If you’ve been seriously injured in Texas because of poor hospital, medical, or nursing care, then contact the top-rated, experienced Texas medical malpractice attorney for a free consultation about your potential case.
