I recently had a doctor’s appointment. My doctor was mentoring a new medical student and he joined us in the examining room. My doctor, knowing I represent patients in malpractice cases, asked if I had any advice for the medical student. One of the things I told him was to be careful with the electronic medical records.
Electronic medical record companies have a product they want to sell to hospitals and doctors. They almost always claim that their record keeping system is easy to use and will save the doctors and nurses a lot of time. They typically do this by using a template for a doctor’s examination, nursing observation or other necessary medical entry. A format will be created and the health care professional is asked to fill in blanks in the format. This usually involves selecting items from a drop down menu. Click, click, click and the entry is complete. If the best word to fill in the blank is not on the drop down list, too bad. The provider must choose one of the options on the list. This has the tendency to produce a record which is not as accurate as it could be in describing the patient encounter.
A bigger problem is that the format tempts doctors and nurses to get lazy and to take shortcuts. So often in medical records there is little change from the last time the doctor or nurse saw the patient and made a record. The strong temptation is to just reproduce the last record and it is so easy to do when using an electronic medical record. When all goes well, this lazy use of a shortcut may never be noticed. But when bad things happen, as they sometimes do, some smart medical malpractice lawyer may go over that electronic medical record with a fine tooth comb and, if short cuts have been taken, it will go badly for the doctor or nurse involved.
I have had a number of cases in which this very thing happened. In each case, a number of entries said exactly the same thing, even down to containing the same typographical errors. In one case, a patient’s tonsils had been removed and yet, on the next two visits, the defendant Physician Assistant seeing the patient recorded that the left tonsil was swollen and discolored, just as it had been before being removed. In another case, the defendant doctor recorded the same discussion with the patient about upcoming surgery, even after the surgery had taken place. In both of those cases, I began the deposition of the defendant by asking if the records were accurate and if everything that they said happened actually happened. After they each testified the records were accurate, they spent the rest of the deposition admitting to their great embarrassment that they were inaccurate.
Medical records are critical evidence in a medical malpractice case. Juries tend to believe what is in the medical records. They are like the Bible. They are God’s word. They are not to be questioned. If it is not in the records, it did not happen. The records almost always support the defendant, so when the credibility of the records is lost, so often is the case for the defense. Inaccurate records have no credibility and neither does the defendant who cut corners and who testified falsely that the records were accurate.
I hope the young medical student takes my advice to heart. He has a long career ahead of him and I will be very pleased if he never gets sued and never has to sit across a deposition table and defend poor record keeping.
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