The documentation of the medical record provides a substantial basis of evidence in a medical negligence case. This evidence would support an accusation of a deviation from the standard of care. Medical records like treatment plans, doctor’s orders, discharge summaries, laboratory findings, medication charts, and medical diagnoses are most effective when it comes to supporting medical malpractice claims. These are the facts that can support malpractice claims by demonstrating the events as they happened.
Based on Candello’s analysis of 65,000 medical malpractice cases closed between 2014 and 2023, approximately 20% involved errors in documenting the care of patients. Cases involving documentation errors had double the odds of closing with a payment.
Accurate medical record keeping remains critical whenever a possible medical error could lead to litigation.
Medical records often come up in malpractice disputes and in many other injury cases, and the contents of the chart can shape the outcome, a point that also holds true for the role of medical records in your personal injury claim.
The Chart Existed Before Anyone Thought About a Lawsuit
Much of the evidence for medical malpractice cases is obtained retrospectively. Depositions are often conducted a long time after the event, sometimes years later, usually in the presence of counsel. Recollection of medical malpractice events diminishes over time. Unlike most other documents, a medical file was created as a clinician assessed and treated a patient without litigation in mind.
Hospital documents must be clearly written and complete, as required by the Medicare Conditions of Participation. Each hospital record entry has to be authenticated, dated, and timed by whoever has responsibility for it. Verbal orders are also subject to these requirements.
Hospitals are held to these standards as a condition of Medicare participation, so the record is most likely created in a format that ties the clinician down to a specific point.
A chart in compliance with the standard is a record of almost minute-by-minute knowledge of the patient. Entries that are incomplete, unsigned, or untimestamped start to raise suspicion.
Ask for the Full File and Not a Summary
Patients hold a federal right to their records. A provider has to act on the request within 30 calendar days and may take a single 30-day extension, in writing, with the reason stated.
What a patient requests matters as much as when. The designated record set reaches past the clinical chart into billing records and other material the provider used while making decisions about that patient.
Which records matter depends on the nature and severity of the injury. These may include files like emergency room documents, admission files to the hospital, imaging files, surgical files, rehabilitation files, and prescription files.
The use of each file is different. Imaging files assist in knowing the level of injury, while billing files assist in noting the cost.
What a Reviewing Physician Reads First
Any case of malpractice does not rest on the patient’s opinion of substandard care but rather on an experienced doctor examining the records and confirming it.
Many states demand that opinion up front, as a sworn statement filed with or shortly after the complaint, and a court can dismiss a claim that arrives without one no matter how strong the underlying facts. Deadlines and qualifications for the signing expert vary enough that the rule in one jurisdiction says little about the rule in another.
Such practices generally lead to earlier, more intensive document gathering, since most medical care will have already occurred and documented before any formal complaint is lodged. Clients have more opportunity than lawyers to take photos and create documents of the medical mistakes and injuries that have occurred. A Marietta medical malpractice lawyer has the experience to help clients gather this documentation and any other helpful information to pursue their case.
A note written eighteen months after an admission recounting the events of the third night is less credible than a note entered a week after an admission.
The Metadata Is Part of the Record
Paper records leave the potential for changes to go unnoticed, but electronic records usually track the trail of amendments. This feature makes it less likely that someone will tamper with electronic records.
Health IT certified under the federal program has to log actions taken on a patient’s information, and the software itself cannot change, overwrite, or delete those log entries. It also has to detect whether anyone altered the log.
The federal health IT office publishes the criteria, and the practical result is an audit trail showing who opened a chart, when they opened it, and when they typed.
Timestamps get interesting once they cluster. An entry that describes a patient’s condition at 2 a.m. but was actually keyed in at nine the next morning, after the patient coded, reads nothing like an entry made at the bedside. Late entries are not automatically improper.
Physicians amend charts for good reasons all the time. But a jury may weigh an amendment logged hours after a bad outcome, such as one made by a clinician after meeting with risk management.
When the Chart Itself Is Wrong
A patient can contest an entry made by a health provider. The provider must act on the request within 60 days of receiving it, either by amending the record or by denying the request. One 30-day extension is allowed under privacy regulations.
Providers can refuse an amendment on set grounds, including a finding that the entry is already accurate and complete. A person whose request is refused can send the provider a written statement of disagreement, and that statement has to travel with any later release of the contested information. Complaints can also go to the provider or to the U.S. Department of Health and Human Services.
Records requested beforehand can be checked for mistakes. Raising any errors early through the amendment process helps save time and resources.
