There are multiple authoritative and informational sources used to establish the facts at hand in a medical malpractice suit. Although expert testimony is certainly among the most used and credible sources in determining instances of veritable malpractice, there are more objective sources such as charts and reports.
In medicine, meticulous record keeping is essential. Records are kept with regard to a patient's medical history and medications prescribed. Wounds are charted, X-rays were taken, blood tests and panels done. There are myriad objective reports presenting irrefutable information which can play a critical role in court.
Types of Reports Used in Medical Malpractice Cases:
- History & Physical (H&P) - Dictated by the patient's admitting physician, this type of report usually begins with the patient's chief complaint and will include present illness, family history of disease, social history/habits such as smoking. This is accompanied by a review of the patient's systems and a head to toe physical, ending with admission diagnosis and plan for treatment. This can be critical in medical malpractice cases, to point to any initial glaring failures on the part of the physician, if any at that point in time.
- Consultation (Consult) - A consult is usually dictated by the physician to whom the patient is referred by the admitting physician, meaning they are usually a specialist in the area of concern for the patient. In addition to a brief patient history and physical, a consult may include X-rays or laboratory findings and conclude with the consulting physician's opinion of the patient's case and a plan of treatment.
- Operative Report (OP) - If and when surgeries are performed, the operating surgeon completes an OP detailing the operative procedure, instruments used and names of surgeons involved. Many other factors of surgery are herein recorded, such as the type of anesthesia, nursing staff, anesthesiologist, sponge count and blood loss for example. The patient's condition at the conclusion of the procedure and time of transfer is likewise recorded. In order for a medical malpractice attorney to establish the facts in a case involving medical/operative minutia, an OP plays a critical role.
- Discharge Summary - At the conclusion of the patient's hospital stay, a summary is prepared detailing all pertinent events and physical findings that occurred during their time there, including lab reports and X-rays. At the end of the report, there is a discharge diagnosis and plan for the patient.
- Radiology Report - A radiology report may be comprised of x-rays, CT scans, MRI scans, nuclear medicine procedures and fluoroscopic studies. It is completed by the radiologist after a diagnostic procedure and includes their detailed impressions and findings.
Although there are many more types of reports used routinely in medical settings, this is a relevant sampling of the types that may be used in a medical malpractice case.
How Reports Are Used in Medical Malpractice Cases
The following is an example illustrating how reports can be critical evidence in medical malpractice cases: A physician orders a blood test for a patient experiencing X symptoms. The blood test shows the presence of Y substance, which is known to indicate Q malady. Despite this, the physician does not diagnose the patient with Q malady but with T malady, which is substantially less serious, and discharges her on the promise that their symptoms will subside.
The patient waits several days and X symptoms worsen. They enter a new hospital, where a different physician successfully diagnoses Q malady, which the patient already presented signs of. The time wasted while the patient was told they had T malady greatly shortened the window of time for the patient to undergo H operation. The patient undergoes it but is left with B disability, in large part due to the wasted time of the faulty T malady diagnosis. The patient sues the first physician for the medical tort of failure to diagnose. The blood test showing the presence of Y substance could be presented in court, alongside expert testimony that Y substance is a telltale indicator of Q malady - substantiating the claim that the first physician deviated from the standard of care owed to the patient by not running further tests and prepping the patient for H treatment.
A report or a test result does is considered very reliable evidence. When confronted with entirely objective evidence, an irrefutable report may work as leverage in achieving a settlement with the opposing party, because it would be difficult if not impossible to refute in court.
Reports & The Standard of Care
If the standard of care in a given field dictates that X-rays or similar reports are to be taken in a specific way, or a specific sector of the body, it may be evidence of malpractice if the plaintiff presents faulty X-rays in court. A lab report and the values it presents can make a critical difference in the diagnosis of a patient. A particular value on a lab report (white blood cell count, blood pressure, cholesterol etc) can trigger different diagnostic and treatment pathways for the patient, and for this reason, they are exceptionally important. A medication report is useful in scrutinizing a healthcare providers choice of prescriptions for their patient. Consistently prescribing pain medication while ignoring the root cause of it may look suspect if presented in court. A wound chart offers a brief but precise report as to the state of a wound.
Another aspect of the standard of care is consulting a patient's medical records when rendering care. This alerts the physician of any possible medication allergies or conditions which may govern the type of care the patient should receive. This requirement is generally waived in emergency situations where immediate care is needed. If the physician fails to review their patient's medical history but the patient incurs no harm as a result, there are no grounds for a suit. However, if the physician fails to review them and the patient is harmed, then the physician may very well be liable. This could include prescribing a medication which the patient was allergic to. If the medical history report is presented in court, there is very little a defendant could do to argue that the information about that allergy was printed in black and white and available for their review.