Attacking the Electronic Medical Record
In their Trial Advocacy column, Ben Rubinowitz and Evan Torgan write that a careful look at electronic medical records often reveals inaccuracies that not only adversely affect patient care, but also serves to undermine the integrity of the entire record. To the extent that the medical record contains false or inaccurate information, it is not enough for the trial lawyer prosecuting a medical malpractice case to expose a limited error. The goal should be to attack in such a way as to show that the entire record is untrustworthy.
September 04, 2015 at 03:24 PM
11 minute read
The electronic age has paved the way for speedy retrieval of medical records. It has allowed for instantaneous access to records that only a few decades ago would have taken hours if not days to retrieve or produce. Clearly, there are many benefits to such records including, theoretically, better patient care. But the problem is that the electronic record is only as good as the individuals who input the information into the record itself. While the record should accurately reflect the details of the ongoing medical treatment, a careful look at these records often reveals inaccuracies that not only adversely affect patient care—the primary goal of all physicians—but also serves to undermine the integrity of the entire record.
To the extent that the medical record contains false or inaccurate information, it is not enough for the trial lawyer prosecuting a medical malpractice case to expose a limited error. The goal should be to attack in such a way as to show that the entire record is untrustworthy, less than credible and a document that is not worth the paper on which it is printed.
Entries and Accuracy
While the electronic age has allowed for speed in the creation of the medical record, it has also allowed for “professional laziness.” Consider first the “copy and paste” option. Rather than taking the time to type an up-to-date patient history, now the medical professional can simply copy and paste that which was documented at an earlier point in time. While the history might have been correct at one time, the passage of time has the potential to make that earlier entry incorrect. Take, for example, the first sentence of the beginning paragraph of a patient's history:
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