Medical records are the heart and soul of a claim for medical malpractice because inaccurate or incomplete medical records are a serious danger for patients.
While modern medicine invests heavily in technology, hospital charting errors still happen because electronic charts still rely on human beings to fill in the blanks. Some of those human beings are careless, disinterested, distracted, tired or simply inept.
Despite all the technological advances of the day, some errors are still commonly seen in cases that go to litigation:
1. Poorly developed histories
Every patient’s medical history is important, including his or her past surgeries, major illnesses, drug allergies and sensitivities, family history and current diagnoses. Something as simple as forgetting to ask a patient if he or she has a latex allergy, for example, can lead to life-threatening allergic reactions.
2. Missing notes
Everything that goes on between a doctor or patient should be documented. Conversations with consulting physicians should be documented, as should conversations between care providers at shift changes in order to avoid gaps in care or confusion. If, for example, a consulting specialist makes a recommendation and it isn’t recorded, it renders the specialist’s assistance useless and could cause the patient to miss a critical part of his or her care.
3. Unrecorded observations
Nurses and nursing aides make up a significant portion of the interaction that occurs between a hospital patient and caregivers. Their observations may end up being critical to a patient’s health and well-being. For example, if a nurse observes that a patient seems inconsolable, that information could mean the difference between a patient who receives important psychiatric care and a patient who ends up trying to commit suicide immediately after release.
4. Failing to record medication issues.
Every time a medication is given, it needs recorded. If a patient’s long-time medication is stopped, even briefly, it needs to be recorded along with information that indicates why it was halted. If a patient complains of anything that could be an adverse drug reaction, especially within the first hour after receiving a medication, that should also be recorded in order to prevent serious adverse reactions.
Anyone who has suffered from hospital negligence should seek the advice of an attorney. For more information on how our firm can help you with a hospital negligence claim, please visit our page.