Prior to the advent of personal computers, all medical records were written by hand. Whenever an attorney needed to review medical records in medical malpractice cases, he or she would have to rely on the handwriting of doctors to understand more about the case. However, it has now become easier than ever to spot deficiencies in the standard of care by reading electronic health records (EHR).
In January of 2014, federal law mandated that doctors use electronic records to reduce errors, improve quality, and save money. Now, more than 83% of physicians use EHRs in their offices. As a result, some medical malpractice cases can have 4 to 10 pages per note.
However, sometimes each note has a complete history, review of systems, and thorough physical exam. Because of simple copy-and-paste methods, some notes are almost identical to others, apart from the date of the doctor visit. Doctors refer to such records as “garbage notes,” because they indicate little about what was considered by the physician during the visit.
EHRs provide many benefits and detriments when it comes to medical malpractice cases. While doctors might miss something important because they were hindered by “garbage notes,” they are still obligated to ensure they create detailed notes to avoid potential accusations of negligence in the future.
Likewise, an attorney who might be using the EHRs to prove negligence will have to look carefully through these detailed and repetitive records to glean information regarding his or her case. It’s vital to discover internal inconsistencies to support such an accusation, such as a new diagnosis without a physical exam description to support it. EHRs are also time-stamped for clinical activity and input of orders, which makes them discoverable and can add to physician liabilities.
In medical malpractice cases, the technology for EHRs can also be used against the patient. For example, electronic pop-up alerts, clinical prediction rules, and reminders for follow-up visits will be sent out automatically by the system, not the physician, and are not always relevant or based on pertinent scientific information. While they were intended to improve care delivery, they have been used to prove the patient didn’t pay attention to important notifications in medical malpractice actions.
If you or a loved one was injured by a negligence physician, let us help. We can help you review the EHR concerning your case to see whether or not your doctor might be guilty of malpractice. Kempton & Russell has more than 60 years of combined legal experience to offer your case. Let our Sedalia medical malpractice attorneys see what they can do for you.
Contact us at (660) 722-4115 or fill out our online form to schedule a free case consultation today.