Medication Errors

Weak Medical Records is ammunition for a claim of Medical Negligence

Part 1 of 6 of Medication Errors

 “For the plaintiff’s lawyer, a case typically comes to his office because of a perceived bad outcome, but stays at his office because of deficiencies in the medical record. For the defense, a medical malpractice case most often begins and ends with the medical record. It is the singularly most important testament to the care which was and was not provided, and often represents the defendant physician’s only ‘memory’ of that care. A poorly documented record can turn good medicine into an indefensible case.”

Steven J. Hippler

On one hand the term “medication errors” is of wide amplitude and is extremely wide, especially with respect to issues of medical negligence and on the other some may not even know what the term actually constitutes or what is a medication error. Though the list of specific events that may be included in the definition of “Medication Errors” is long, it can be categorized in six broad categories.  

This blog discusses the impact, relevance of maintaining of medical records of patients in order to avoid instances of medical negligence arising from medication errors. Medication Errors may arise from failure by physician to update or review medical records of the patient before recommending any medication.

Good documentation protects physicians and other health professionals against claims of negligence. Aside from medical-legal considerations, the most vital reason for doctors to maintain precise, reliable medical records is that good documentation safeguards a patient. Medical records contain material required to inform physicians of past and present treatment choices, and to provide evidence that such care was suitable.

Medical records are the most significant evidence that doctors and hospitals offer in their defense against a medical negligence claim. Proper medical records maintained by the doctors are important are relevant in defended conflicting, undocumented versions of events told by opposing parties as the medical records / documentation directs towards the documentation that was done before and during the time medical care rendered by the doctor.

Where poor medical records make it problematic to decide whether an adverse outcome resulted from factors beyond the physician’s control or from negligent medical care, on the other hand, good documentation protects physicians and other health professionals against claims of medical negligence.

Typically, when a patient asks an attorney to file a malpractice claim against a physician, hospital or other health professional, most attorneys obtain copies of the pertinent medical records for review by an independent medical consultant. The reviewer is asked to determine, based on the documentation, if the treating physician(s) provided appropriate care — and whether the physician was negligent. The strength of the documentation often is the deciding factor in whether a plaintiff pursues a claim and in how effectively defendants and their insurers can mount a solid defense against the allegations.

DO’s and DON’Ts for Doctors and Hospitals

Serious diagnostic and treatment errors have resulted in injury and litigation because the medical reports were not available or if available, were not proper. Considering that our legal system is oriented to documents and documentary evidence holds priority over oral evidence, it is only fair to spend some time preparing records rather than spending time, money and energy in litigations. Medical records are central documents in the defense of any malpractice case and therefore require some attention and dedication. The medical records usually are the most definitive piece of evidence presented at any trial during Medical Negligence.

The DO’s

1. Use well-organized, neatly-maintained patient charts,
2. Note the details of every visit and check up in clear and conscious manner
3. Write all medical records / progress / documents legibly
4. As an alternative to 3 - dictated and transcribed medical records
5. As an alternative to 3 and 4, consider using electronic medical record (electronic evidence is admissible in court of law)
6. Maintain a record of all the allergies, current medications, names of other doctors on duty at the time of recording,
7. Document “informed consent discussions” carefully
8. Fill in the problems being faced by the patient, in the charts, most appropriately in order to enable different doctor on duty to treat the patient appropriately,  
9. Fill in or void spaces on forms and transcription and place your initials there in order to avoid accountability issues,
   
10. Sign all entries or at the least initial all entries in order to avoid credibility issues
11. Document significant phone conversations with dates, names, and content
12. Chart all medication prescriptions and renewals completely and with details and reasons
13. Document “referral notes” unambiguously
14. For example, instead of “to see GYN,”, prefer writing “Pt urged to see her GYN promptly for vaginal bleeding; patient understands urgency.”
15. Initial or sign lab, X-ray, consultants’ reports as evidence of your review
16. Initial or sign questionnaires filled in by patient (if any) as evidence of your review
17. Include sufficient details of exam findings in progress notes
18. Supplement narrative text with line drawings, diagrams and templates
19. Document patients’ noncompliance in the progress record
20. Chart evidence that patient education information was dispensed
21. Document returns visit advice in each progress note
22. Document failed and canceled appointments in the progress record
23. Resolve medical problems from previous visit in the chart i.e. how the said problem was been or is being treated
24. Write unambiguous “return-to-work” or “school” orders
25. When amending progress notes, include the date, time and, if the reasons for the amendment are not obvious, explain the change. 

The DONT’S

1. Avoid using sticky notes or unattached slips or papers on the charts or medical records,
2. Avoid unexplained cross-outs, write overs or squeezed-in entries
3. Avoid leaving any blank spaces in forms, charts, questionnaires and consent forms
4. Avoid unsubstantiated subjective remarks in the progress record
5. Avoid criticism of other professionals / doctors in chart notes
6. Avoid untimely dictation of medical records
7. Never amend or correct a medical record after receipt of notice of a potential claim. 

The time is now, the time is right

Ensuring that medical records are well-organized and reasonably complete may add a few minutes per chart to the physician’s day. But, physicians whose inadequate records were partly responsible for their involvement in litigation can attest to the fact that the amount of time spent in deposition, meeting with legal counsel, worrying about the case and its effect on their personal life and professional reputation, or preparing for and attending trial far exceeds the time it takes to maintain adequate medical records.