Electronic Medical Records

Electronic Medical RecordsMany hospitals have been making the move, gradually or all at once, to electronic medical records.  These records can create unique challenges and opportunities for victims of birth injury malpractice who investigate their case.

How Doctors And Health Care Providers Use Medical Records

Some hospitals enlist the use of “scribes,” people who follow doctors around all day and record notes about their conversations with patients and their instructions to nurses.  These notes, whether handwritten or typed from the outset, are typically transcribed and delivered to the doctor within a few days, and the doctor will have the opportunity to revise and sign off on them to verify accuracy.  It’s no surprise that many doctors don’t actually read the notes, and just rubber-stamp the notes of the scribe.  This can cause interesting problems, because the scribes often have little (if any) medical training, and they may misinterpret or misunderstand the substance of the conversations.  On the other hand, it provides in many cases a more clear record than if the doctor’s own notes were relied on, because of the short amount of time many doctors spend placing notes in the patients’ records.  In any case, lawyers may need to conduct depositions of the scribes or request their original notes to verify events during labor and delivery.

Electronic medical records sometimes put patients at a disadvantage.   Some computer programs relied upon by hospitals have fewer areas for general notes, and instead focus on checkboxes.  This can impact the amount of information a doctor or other health care provider inputs into patient charts.

Altered Medical Records

In days past, our lawyers have sometimes had reason to suspect that a medical record, whether a single notation or entire pages, were altered or created after the fact.  This may be because the parents remembered things differently than the records, or perhaps a note just didn’t quite fit.  We would sometimes hire experts, like forensic handwriting experts or ink analysis experts.  Using sophisticated scientific methods, those experts can determine how many pens were used and can even determine the relative age of different writing samples.  A jury presented with testimony of evidence tampering is entitled to believe that the tampering was done with an intent to cover up negligence.

With electronic medical records, forensic computer experts may be required to uncover fraudulent medical records.  In the age of computer entries, this is often simple to discover if the lawyer knows that some records are kept electronically.  In many cases, records should be requested as paper or PDF copies (as they would appear in the physical chart), and in “native” format (able to be viewed through the hospital’s software program).  The native format will preserve any hidden metadata which contains information about specific entries and revisions.

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Your lawyers should have intimate familiarity with the process of charting and creating medical records.  It is important that they be able to identify whether records were altered, removed, or added in an attempt to cover-up negligence during pregnancy, labor or delivery.  Evidence of these actions can go a long way to convincing a jury that the health care providers negligently caused injury.  If you have questions about a birth injury malpractice lawsuit, contact our lawyers at 888-452-4912 or fill out our online contact form Contact Us.