What is a "medical record" and why is it important that it be accurate? A medical record is generally defined as electronic or paper documents containing factual information regarding a patient’s health status and the corresponding medical opinions based on that information.

An inaccurate record can result in poor healthcare. Inaccurate records containing erroneous diagnostic codes can also adversely impact efforts to get bills paid. An accurate medical record also provides protection of the legal interests of the patient when it comes time to prove facts about medical care in a trial.

In one of our earlier posts, we pointed out that on the patient’s end, it is important to be accurate, clear, and detailed during visits to the doctor. A responsible and careful medical provider will want to well document a patient’s medical history, exam, and the medical decision making involved in treating a patient. A careful physician or nurse will make an effort to be complete and legible in making written patient notes. Abbreviations will be standardized and procedures will be in place as to how to correct errors without changing the original entry. For example, on handwritten notes, errors might responsibly be corrected with a single strike-through line that is initialed, dated and identified as an error. White-out products used to correct errors result in a record that can be challenged as misleading. Removing and replacing a page of a record to cover up an error is never acceptable.

In protecting a client’s interest in making a medical malpractice claim, we carefully examine our client’s medical records. Where appropriate, we seek information about the written policies, procedures and standards of conduct regarding medical records, and check to see if these standards have been followed. We have on several occasions found that records have been tampered with in an attempt to cover up mistakes. If you have obtained your medical records, and are concerned that the copy you have been provided has been tampered with or altered, please do not hesitate to contact us for a consultation.

Not only is it important for medical reasons that a patient provides accurate information to a treating physician, it is important from a legal standpoint that medical records contain accurate information. It is not a very frequent occurrence, but occasionally we see records of a person who suffered a major injury, and some additional minor injuries, that reflect that the patient completely failed to report to the physician who sees them in follow-up to an emergency room visit, anything other than the major injury. Usually this will happen where the follow-up treatment is to a physician with expertise in orthopedic injuries, and the patient also has an eye injury or an injury in some other area of the body with which the specialist being visited does not deal. If in such a situation, the patient is shown a drawing of a person and asked to mark all areas where pain is being felt, the patient should rightly mark pain in the eye or head region of the body, as well as pain in the back or neck or other area with which the orthopedic specialist is expected to deal. To neglect to mark all areas of pain not only may impact medical care (such as being prescribed medicine that may help your back, but make the eye worse), it can create an inaccurate record that an opposing attorney can exploit and ask “well you say your eye continuously gave you pain for weeks, but when you saw Dr. X and were asked to mark all areas of pain, you did not mark that your eye was giving you pain, did you”?

Recently, the Indiana Supreme Court held that if the police enter a home illegally, the person whose home has been illegally entered has no right to resist the police. In the decision the Court notes that the law for centuries has considered a person’s home to be a protected place subject to defense by the occupier of the home. The decision appears to come out against the Fourth Amendment which clearly states that “[t]he right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.” However, the decision is unusual, because the police were called to the home over a domestic dispute and argued with the homeowner outside the home. The homeowner then went inside the home to seek refuge and the police followed and the homeowner then allegedly resisted arrest. The language of the decision suggests that police can enter a person’s home for any reason – or no reason, or an unlawful reason – and the homeowner must stand aside and let them do whatever they desire. Writing for the majority of the high court, Justice Steven David stated, “[a] right to resist an unlawful police entry into a home is against public policy and is incompatible with modern Fourth Amendment jurisprudence” (emphasis added). He also opined that, “allowing resistance unnecessarily escalates the level of violence and therefore the risk of injuries to all parties involved without preventing the arrest.” — While many argue that the decision oversteps the bounds of the Constitution, and quite likely it does, unless overturned by the federal courts or the state legislature, Indiana residents would do well to consider the consequence of resisting properly identified police officers who enter the home without a warrant or probable cause, at least until the decision has been further reviewed.

Whether you are a student signing up to take a college course, or opening a new bank account, or signing a document authorizing a car repair, take the time to read what you are being asked to sign.

It is becoming increasingly common for Corporate America to rely on adhesion contracts to force people to accept mandatory binding arbitration. Such language often will bar you from filing a lawsuit in court which will prevent you from having a jury of your peers decide any dispute that may arise between the parties. Imposing mandatory arbitration on consumers, employees, and others, is primarily designed to eliminate the threat of a class action. While the class action process has occasionally been abused by consumer groups, the vast majority of the time, a class action is the only tried and true legal tool available to enable consumers to challenge unfair action by companies that often have a greater financial ability to hire lawyers and fight to prevent consumers from obtaining fair compensation. For example, the average cost to file a lawsuit is $200, but if you are forced into binding arbitration you will not only have to pay your lawyer, but you will have to pay the arbitrators, sometimes as much as thousands of dollars, and may even have to pay the corporation’s lawyers if you lose.

Our office frequently consults with people who have suffered a fire loss, theft or other property loss. On every occasion we are asked "do I have to cooperate with my insurance company?" The short answer is "yes".

The long answer is "absolutely yes, you must cooperate." And, it is to your advantage to be completely truthful, no matter how much the insurance company might provoke your patience.

When you buy insurance, you and the insurance company enter a contract, which is commonly referred to as an "insurance policy". Every insurance policy requires complete cooperation in providing information to verify that the loss occurred, and the value of the loss. Every policy requires that you submit your statement of claim and proof of loss under oath. This means you swear to tell the truth under penalty of perjury. If you are untruthful it will give the insurance company grounds to deny your claim.

It is not unheard of for people to report that after answering an insurance adjuster’s questions they feel as if they have been called in to be interrogated by the police. Sometimes requests for financial information or phone records seem to be irrelevant and burdensome. Nevertheless, accurate information must be provided. Moreover, it is important not to take requests for information personally. An insurance company has an obligation to verify that a policy holder is making a legitimate claim. Unfortunately, some people claim to have property that they never actually owned, or even destroy their own property and then try to collect insurance proceeds. Insurance claim adjusters play an important role in making sure to pay only people who have legitimate claims.

Even seemingly insignificant misreporting of facts, such as not accurately reporting the giver of a gift, or overstating your income, or exaggerating the value of a lost item of property, can inadvertently give an insurance company a basis to question your claim. Consequently, always cooperate and be truthful.

However, and this is very important, you as an insured have rights too. Your rights are many, and too numerous to list here. The bottom line is that an insurance company must act in good faith toward you. You can help insure that it does by documenting everything that the insurance company asks you to do, keeping copies of everything you are asked to turn over to an adjuster, including anything you are asked to sign. If an insurance company records your statement or records a conversation, ask it to preserve the recording in case you later need a copy. Do not hesitate to ask the insurance company to put instructions in writing to you so that there can be no dispute as to anything you are asked to do. Lastly, do not hesitate to give our staff a call if you are at all uncertain about your insurance claim rights and responsibilities. Our staff is always willing to arrange for you to consult with one of our attorneys.