Everyone has heard a joke about how the handwriting of doctors is so bad.
As a Houston, Texas medical malpractice attorney, I used to spend a lot of time with my legal nurse consultant trying to decipher what handwritten medical entries said. With the advent of electronic medical records, this is not so much an issue anymore.
Some facilities, though, use a mix of handwritten and electronic medical records. Many anesthesiologists and certified registered nurse anesthetists, for example, still use handwritten record that they complete during the procedure. Just last week, we were trying to interpret some handwriting that looks like hieroglyphics.
While there are many things not to like about electronic medical records, one positive thing sticks out in my mind—there is more security to prevent after-the-fact alteration or tampering with medical records.
In my practice, I always recommend that patients considering a medical malpractice lawsuit obtain a complete set of medical records before leaving the hospital. When a client hires our law firm, we order the relevant medical records before filing the lawsuit. Then, once the lawsuit is initiated, the hospital, facility, or surgery center produces another set in written discovery toward the beginning of the litigation.
My nursing staff and I then carefully compare any differences among those sets of records. In one medical malpractice lawsuit that I handled several years ago against a Houston hospital located in the Texas Medical Center, the difference was over 300 pages. My clients in that serious brain injury case were concerned that physicians and nurses had, so to speak, doctored the records.
To get to the bottom of it, I demanded to depose the medical records custodian for the hospital and even had an oral hearing about it with our trial judge.
In old-fashioned handwritten records, clever healthcare providers wanting to change unfavorable entries could sometimes cover their tracks. This is much more difficult to do because of audit trails generated by electronic medical records. Audit trails are electronic logs that record the user ID, date, time, and location for every time someone reviews, adds to, or makes changes to the medical record.
Audit trails ended up being a significant factor in a recent Chicago wrongful death medical malpractice case involving a botched pacemaker surgery.
In that lawsuit, the patient went to the hospital for insertion of a pacemaker to control an arrhythmia. During the pacemaker surgery, the surgeon cut and artery and, according to lawsuit, did not quickly recognize the bleeding. Over my many years of practice, I have handled cases where an artery or organ is accidentally cut or perforated during the procedure. While it is not always a violation of the standard of care to cause such damage accidentally, it is a major issue when the physician or surgeon does not timely notice and repair it.
As the Chicago litigation proceeded, the plaintiffs discovered that the doctor entered the patient’s medical chart “on a number of occasions” after she died. Even though the hospital’s electronic medical record system did not show exactly what changes were made, it still did not look good for that doctor. This conduct undoubtedly caused many people to wonder what he was doing in the medical records after his care the patient was complete, and, in fact, the patient was deceased.
In my experience, the electronic medical records software currently used by most hospitals and physician offices has detailed audit trails that would allow potential medical record documentation misconduct to be easily uncovered.
Understanding how to obtain, decipher, and investigate medical records is another reason for patients and family members seriously injured in healthcare to hire an experienced medical malpractice attorney.
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If you or a loved one has been seriously injured by hospital, nursing, physician, or surgical care, then the experienced medical malpractice attorneys at Painter Law Firm, in Houston, Texas, are here to help. Click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.
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Robert Painter is a 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 against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.