Electronic health or medical records are increasingly replacing paper files in doctor’s offices nationwide. Designed to streamline patient medical care, they include everything from your vital signs taken by the intake nurse on the day of your appointment to the results of the lab work that you had done a few days later on your doctor’s orders.
They are also supposed to contain other critical pieces of information: the tracks someone needs to follow if they want to understand why your doctor made one decision over another. Those tracks could become critically important if your doctor’s decision turned out to be a mistake, leaving you with a worsened condition or a permanent disability.
In the case of medical malpractice and doctor errors, electronic records are often a malpractice attorney’s best evidence. They can be cumbersome for doctors to use and understand and filled with potential problems — like templates that will automatically fill in needed, but incorrect, information.
Electronic records are also easily altered. The ability to change your record quickly and easily may have an important role in your medical care, but it can also tempt doctors or other healthcare providers to cover up mistakes.
Fortunately for injured patients, changes made to electronic records are tracked internally. Doctors and other healthcare providers aren’t always aware that they leave behind a digital record if they try to go in and add a note or two that boosts their version of events. Getting caught at it, naturally, cripples their defense.
Careless copying and pasting health information from one page to the next could mean embedding misinformation deeper into the record. It could also cause your physician to rely on incorrect information that keeps popping back up in the system. It might cast doubts on the credibility of a doctor who says that he or she was actively engaged in your care when he or she couldn’t be bothered to take down a unique record of your visit that day.
Electronic records can also show something else that doctors don’t expect — exactly how much time they spent reviewing your test results or other information before coming to a decision about your care. If your doctor only spent a few seconds looking at your records and test results, that could be strong evidence that his or her level of care was substandard and negligent.
Source: HealthIT.gov, “What information does an electronic health record (EHR) contain?,” accessed Dec. 01, 2016