Medical records contain vital information about your health and medical history, including a variety of documentation on clinical findings, diagnostic test results, preoperative care, operation notes, post-operative notes, and daily notes about progress and medications if you’re hospitalized. In the event a doctor, nurse, or other medical professional makes a mistake in your chart, you could suffer unexpected and preventable injuries.
Poor medical record keeping is not an infrequent occurrence. Whether communication errors, technological difficulties, or plain negligence is the cause, patients are being put at risk unnecessarily—and often unknowingly. While not every instance of inaccurate record keeping is grounds for a medical malpractice claim, there are situations that do apply and can result in legal action. Let’s take a look at medical record inaccuracies and how they can result in medical negligence.