Unfortunately, it is a common occurrence that one or more medical records in a personal injury case will contain false information and/or glaring omissions. This blog will address this topic. I am going to break it down into two categories: Acute care and follow-up treatment.
Part I – How Medical Record Errors Happen
I. Acute Care
As for acute care, my background provides insight on medical record errors. As I have mentioned in prior blogs: Prior to attending law school, I was a professional Florida Paramedic – Firefighter working in New Port Richey. Prior to attending Paramedic school, I worked in a Pasco County Emergency Room as an EMT. This background allows me to better understand how errors occur in an acute treatment setting.
A hypothetical: A 72 year old female trips over a parking bumper at a shopping plaza in a dimly lit area, striking her head on the pavement. Some Good Samaritans who heard the fall help her inside the mall to a bench. The victim has sustained closed head trauma, and loses consciousness prior to EMS arrival. EMS transports her to the ER, where the record states that a “72 y/o w/f slipped and fell on liquid at mall while shopping, striking the occipital area of head.” This type of error is NOT uncommon.
The reality: ER doctors and paramedics are trained to get to the bottom of mechanism of injury. I actually have to defend these errors to some extent. What they need to know is “why is this 72 year old unconscious?” “What caused it?” Once they ascertain blunt head trauma from a fall, it really doesn’t matter all that much whether the fall was caused by a curb in the parking lot or water inside the store. What matters is that the patient went down hard on the back of her head from a fall, and that it was caused by something other than just acute loss of consciousness.
II. Follow-up Care
Errors in medical records during follow-up care can be far more problematic than in acute care records. In follow-up care, there is more of a dialogue between patient and doctor. Moreover, the doctor is not occupied treating 2 chest pain patients, 4 flu bugs, and a variety of other ailments at the same time. During follow up care, doctors are far more likely to defend every entry in the record as the gospel truth as to what a patient told him or her.
Part 2 – How To Legally Deal with Medical Record Omissions and Incorrect Entries
I. Acute Care
As for an incorrect mechanism of injury entry in EMS or ER records, many times it is not a problem. As an attorney, I definitely want to address it, and the first thing I’ll do is get witness statements as to how the accident happened. If there are no witness statements, then I have had a client sign an affidavit addressing the cause of an injury. If a lawsuit is eventually filed in the case, then it can be sorted out at depositions. All that said, many times it is obvious that the entry is not accurate, and it does not even become an issue during negotiations. Nonetheless, if the case is not settled and winds-up in court, then it must be addressed.
If the problem with the acute care record is that the client’s symptoms are not accurately documented, then subsequent records will be important to establish a causal link between the trauma and injuries. Many times, an injured patient will only focus on the primary complaint, and ignore telling ER staff about less severe symtoms.
II. Follow-up Care
It is vital that a personal injury victim have an attorney who monitors medical records. I have had countless occasions where a client tells me throughout a case that he or she has pain in an area that remains undocumented. If there is a prolonged absence of documentation of symptoms, then it can be very problematic to a case. In my experience, there are two primary reasons that some of a client’s symptoms are not documented by a treating doctor. First, the client remains only focused on the primary complaint, and omits other symptoms during medical appointments. Another is that the treating doctor is hyper-focused on the chief complaint, and not documenting everything the patient is reporting. Regardless, the longer a client’s symptoms go undocumented, the bigger the problem it is to prove those injuries in Court.
SUMMARY
As a personal injury attorney, I realize it is important to listen to my clients, and check in with them frequently. Additionally, I keep my own specific secured notes as to what a client is telling me. As I review medical records during a case, if a client’s complaint is not showing up in the records, this is something that needs to be discussed with the client ASAP. Is he or she reporting the symptoms to the doctor? Is there some type of communication breakdown between client and his or her doctor? It is important to realize how common an issue this can be, and to be certain that when hiring an attorney, he or she will be monitoring records throughout the case. It is also important the clients be made aware to report secondary complaints to his or her doctor. If injured in an automobile, I am available for a free consultation, and can be reached call me 727-848-8892 or contat me via the form on this website. It would be my pleasure to help.
