In a medical malpractice case, the main evidence is the medical record. The patient’s chart is the reliable resource to establish regulatory compliance, accreditation and other important signifiers. Medical charts are also indispensable when it comes to deciding the reimbursement due to the provider. The documentation in medical records has to be flawless and in keeping with acceptable documentation practices. However, often medical record documentation is erratic and this creates a lot of hassles for the medical reviewer. The paralegal or other staff in an attorney’s office attempting to extract relevant information from the medical records may find incompetent/erratic/confusing documentation quite distressing.
Common Problems in Documentation
- Inaccuracy in recording the chronology of events. Often medical events recorded appear out of sequence and non-existent delays may seem to exist, which is a grave error with regard to time-sensitive events such as resuscitation efforts.
- In the case of written records, illegible writing can be really bothersome.
- Difficult-to-read abbreviations, symbols, acronyms, slang and euphemisms can very easily be misinterpreted. Other issues include scratches, alterations, scribbles, and correction fluid that question the credibility of the medical record.
- Correct documentation practice also demands that there should be a clear-cut distinction between reporting medical diagnosis and nursing diagnosis. This is often not followed.
- Another major problem encountered in medical records, which creates inconsistencies, is the existence of duplicate and triplicate entries.
- Missing information in medical records include that related to medication administration and its effect. Often, insufficient documentation makes it difficult to understand whether the medicine worked or not, whether another was prescribed and other such important details. This can create legal issues, especially with regard to held medications. When appropriate documentation regarding why the medication was not given is missing, held medication may be interpreted as a medication error of omission.
- Discharge notes also pose problems, when they do not clearly contain an evaluation with regard to the presenting complaint. All discharge instructions given need to be documented to prevent future legal issues. Medical record review become difficult when discharge notes do not indicate important aspects such as whether the patient was able to comprehend and repeat the instructions, the person’s level of distress and other signs of clinical stability, and whether any witnesses were present at the time of discharge.
Missing documentation, errors and other issues in medical records can be rather challenging if you are untrained in reviewing medical records. On the other hand, an expert medical review team can easily identify such problems. They can also make arrangements to secure the missing records, if any. A competent medical record review company with a professional review team can help in streamlining all medical records pertinent to a case.
