Can Inaccurate Record Keeping Result in Medical Negligence?

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.

Common Mistakes on Medical Records

When you think of medical negligence, you probably think of mistakes that occur when dosing medicine, performing surgery, or evaluating and diagnosing a patient. Sometimes, mistakes like that are the direct result of someone keeping inaccurate records in a patient’s chart. Some of the most common mistakes seen on medical records include the following:

• Incorrect Symptoms. Whether a nurse or doctor records a patient’s symptoms incorrectly or disregards a patient when they initially outline what they’re experiencing, medical records with incorrect symptoms can easily lead to a missed or failed diagnosis. Depending on the condition the patient is actually suffering from, a mistake like this could prove to be fatal.
• Wrong Medical Condition. Medical jargon is complex, which means that even misspelling a word or mixing up a single term in a patient’s chart can result in recording an inaccurate medical condition. If that happens, it’s unlikely the patient will receive the proper treatment they need to recover.
• Inaccurate Treatment History. Treatment history is crucial—especially when someone suffers from a chronic or debilitating illness. This tells doctors what has and what has not worked for you in the past. If your treatment history isn’t documented accurately, doctors could prescribe ineffective treatments and your condition could get worse.
• Wrong Patient. If a communication error results in a medical professional mixing up two patients, those two individuals are likely to experience complications—especially if they are prescribed medication they are allergic too or that will not help their condition.
• Incomplete Medical History. If portions of your medical history, including evaluations, diagnoses, treatment plans, or recovery notes are not recorded properly, your medical records will be incomplete. This could result in complications with future treatments.

When nurses, doctors, surgeons, and medical specialists do not have access to accurate medical records, they may struggle to properly diagnose and treat their patients. Depending on the circumstances surrounding the inaccurate record keeping, medical negligence could be at play.

Inaccurate Record Keeping and Medical Malpractice

It’s no secret that medical personnel at many hospitals and doctors’ offices are overworked—especially when understaffing is an issue. A problem like that, which should easily be resolved, can result in avoidable mistakes—like listing inaccurate information on a patient’s medical chart. If understaffing is to blame for a patient’s suffering, that patient can take legal action in an attempt to hold the facility accountable for not ensuring they have enough employees to properly manage their workload and patient needs.

Understaffing isn’t the only issue that results in inaccurate record keeping. According to a study published in the National Center for Biotechnology Information (NCBI), physicians’ illegible handwriting is a contributing factor to hospital errors. If a pharmacist, nurse, or other medical professional isn’t able to read a doctor’s handwriting and fails to seek confirmation, the patient could sustain injuries.

As mentioned, not every instance of inaccurate record keeping is considered medical negligence. Because of that, you’ll want to work with a lawyer who understands what malpractice is and how it’s proven. If you think you have a claim, Thomas Law Offices can help.

Contact Thomas Law Offices in Cincinnati

If you’ve been injured in a hospital or doctor’s office in Ohio and believe a medical professional’s negligence is to blame, you may have grounds to file a personal injury claim. Doing so, especially in the area of medical malpractice, can be a complex process. Fortunately, a lawyer from Thomas Law Offices is prepared to guide you through the matter and fight for your right to full and fair compensation.

We recognize that the damages associated with a med mal injury vary significantly from client to client. That’s why we look at every case from a unique perspective to ensure we provide the best legal representation possible. To learn more, contact us today.