Medical Record Accuracy

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.