An alarmingly high number of Utah malpractice cases have been linked to documentation errors in the medical setting. Mistakes in the diagnosis or treatment of medical conditions may be the ultimate outcome of this poor documentation and recordkeeping. Whether documentation is incomplete, inaccurate or illegible, mistakes or negligence in patients’ medical charts can lead to adverse health consequences and even death. Any form of charting error, if it results in harm to the patient, may provide a strong basis to pursue a medical malpractice claim.
Inadequate Documentation
The rule of thumb regarding medical documentation says that if something isn’t noted in the patient’s record, it didn’t happen. Yet doctors and other health care professionals often fail to chart all important information. They may neglect to take a complete medical history, leaving out past illnesses or drug allergies that could affect the diagnosis or treatment of a health condition.
Medical professionals may also fail to fully detail a patient’s course of treatment or to note what was discussed during a patient visit. Documentation errors in some cases have been reported to involve an inaccurate or improper transcription of a doctor’s audio recorded notes for the chart. When information is left out of a patient’s official medical record, the omission can directly affect the outcome of treatment.
Electronic Charting Problems
Most healthcare facilities now document patient information electronically, through the use of e-charting tools. While this may help avoid documentation errors related to illegibility, it may lead to other issues. Many electronic chart applications utilize templates that automatically populate default information into a patient’s record. This may be convenient; however, it sometimes leads to inaccuracies in the medical record, particularly if medical professionals fail to correct any errors in the pre-filled data. In some cases, electronic charts reflect the fact that doctors often copy and paste medical records without taking care to update the patient information.
Errors in Medication Documentation
Medication errors harm millions of people across the country every year, and they are responsible for a significant number of malpractice lawsuits. Improperly documenting a patient’s medication can lead to the patient getting the wrong medication or the wrong dosage. Medical professionals in the hospital setting sometimes fail to record that a drug has been administered, which can lead to a toxic overdose when the patient receives the medication a second time.
In today’s medical setting, patients are typically handled by a team of professionals, including physicians, nurses and technicians. Accuracy in medical records is essential to provide a proper standard of care for patients. If you or a loved one has been adversely affected by errors in medical documentation, schedule a consultation with the professional attorneys at Rasmussen and Miner to discuss your Utah malpractice claim.
