Medical documentation and your health

You expect the information on your medical records to be accurate. However, the more doctors you see and the more conditions, illnesses or injuries you have, the greater the possibility of a breakdown in keeping your records up to date.

The accuracy of medical record documentation is a subject for continuing discussion between the medical and legal communities, as malpractice cases are often an effective means of holding negligent providers accountable.

Patient input

When you visit the doctor, a nurse or assistant usually sits with you to take down basic information. This includes listing the medications you take and any allergies you have. Problems may develop when more than one health care professional treats you. Although it is a good idea to always bring a current list of your prescriptions and allergies, each provider should ensure that he or she has records from visits made to others. These should show past and current treatments with medications and allergic reactions included. If someone does not update this information correctly, a doctor could inadvertently prescribe you a medication or treatment that causes you harm.

Beyond accuracy

Even though your records may have accurate information in them, poor legibility or organization could render them difficult to interpret and lead to medical errors. Other aspects of record keeping that may affect your health include timely updates and thorough entries. If your doctor does not enter notes from your visit right away, for example, he or she may forget important details that led to the decisions made for your care. If your health problem gets worse, the doctor may not be able to show the pertinent reasons behind the treatment or medication, which could indicate negligence.

The next step

If you suffer an adverse event such as a medication error, a missed diagnosis or an illness that gets worse instead of better, it is important to report the circumstances to the provider or facility where you received care. Most hospitals have a reporting system already in place and can guide you in the information you need to provide. When the incident costs you in the form of unnecessary pain and suffering, medical bills and diminished quality of life, it may be a good idea to speak to an attorney about addressing the issue through the legal system.

Written on behalf of Friedman Schuman. Contact our firm for a consultation to discuss your legal matter.