Incorrect chart information winds up in medical malpractice cases

Posted By Kinnard, Clayton & Beveridge || Apr 10, 2013

Physicians in Tennessee have an obligation to properly communicate and document all decisions made regarding a patient. This includes making note of whether a patient's medical charts were reviewed, writing down any discussions with other medical staff originally made through text messages and making sure all the information in a chart is correct.

When it comes to medical charting, a lack of information is one of the common reasons why physicians and other medical staff find themselves facing a medical malpractice lawsuit. For the doctors, medical charting errors can make them look dishonest and careless. The common question that arises is that if this doctor was taking his or her job seriously, wouldn't the notes regarding the patient be correct and up-to-date?

Technology also comes into play. Many times physicians communicate with other doctors and nurses via text messaging. These text messages can include check-ups on a patient, but can also shape how certain decisions are made. If these messages are not properly charted, there is no proof the texting even happened and it can look like no thought was put into a medical decision.

Technological advances also means many physicians use e-charting. Many times these electronic charts have a template a doctor fills out. Many of these templates also have default information. This means there is a risk of default information remaining in the chart, which would be incorrect. Again, this can end up being used in court in a medical malpractice case to make the claim that a doctor was careless.

In the end, the take home message is that doctors need to be mindful when it comes to e-charting and that patients should remember the information contained -- or in some cases not contained -- in these charts can wind up being entered in as evidence in a medical malpractice case.

Categories: Medical Malpractice
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