Your medical record documents your medical care, treatment plan, and observations. Your health record is incredibly important in communicating your care in the hospital. Problems in your medical chart can mean problems with your medical care.
Medical documentation errors can result in wrong treatment, wrong medication, and even wrong surgery errors. Fortunately for victims of medical errors, medical documentation errors can also be used as evidence that they were improperly treated and can support a medical malpractice claim.
It can be difficult for the average patient to know if there are problems in their health record. However, an experienced medical malpractice team with medical expert review can identify problems in the medical records and use this to support a claim for compensation.
If you think you may have been injured because of a medical error or miscommunication, contact an experienced medical malpractice lawyer for legal advice about your rights.
What Are Medical Documentation Errors?
According to the National Cancer Institute, an “electronic medical record includes information about a patient’s health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans. Electronic medical records can be seen by all healthcare providers who are taking care of a patient and can be used by them to help make recommendations about the patient’s care.”
Medical documentation errors are errors in the medical record. There are different types of medical documentation errors. Some examples of medical documentation errors include:
- Failure to document
- Failure to date and sign an entry
- Missing documents
- Messy handwriting
- Documentation cover-ups
- Wrong abbreviations
- Drug name mix-ups
- Wrong patient documentation
- Transcription errors
Medical document errors can also be made by anyone involved in your care, including doctors, nurses, health aides, or surgeons. Documentation mistakes can also involve administrative errors or IT problems. Bad documentation can cause a patient to undergo improper procedures or drug administration. It can also fail to document what really happened. In some cases, a negligent doctor may even try to go in later and change the documentation to cover up a medical error.
Making Mistakes in Medical Documentation
To err is human. Everybody makes mistakes. However, in healthcare, the consequences of a mistake can be tragic. Giving a patient the wrong medication, operating on the wrong body part, or failing to monitor a patient undergoing surgery can cause serious injury, disability, or death.
In many parts of healthcare, there are multiple people involved in your care who look at the medical records. Those doctors, nurses, and providers can act as a backup safety check to recognize possible errors. Unfortunately, many medical documentation errors are not noticed, even by healthcare professionals who should know better.
Many of us have made mistakes by writing the wrong date, writing down the wrong phone number or address, leaving off important information, or writing so illegibly that we can’t read it later. Doctors can make similar mistakes in medical documentation. How can these simple mistakes lead to a serious medical injury?
For example, writing down the wrong address could mean a patient starts or stops a medication at the wrong time. Writing down the wrong patient number could cause a patient mix-up, including wrong-patient surgery errors. Leaving off important information like a patient’s allergy to certain medications can cause a severe allergic reaction or anaphylactic shock.
Medical Record Requirements
Complying with medical documentation requirements is part of a healthcare professional’s standard of care. Medical providers are trained to follow certain standards and protocols when caring for a patient, including proper documentation.
The healthcare industry knows how important proper medical documentation is in patient safety and regularly provides training and oversight to ensure the requirements are being followed.
The Centers for Medicare & Medicaid Services (CMS) put out a fact sheet Complying With Medical Record Documentation Requirements. According to the report, common insufficient documentation errors include:
- Incomplete progress notes, including unsigned, undated, and insufficient detail notes
- Unauthenticated medical records, including no provider signature, no supervising signature, illegible signatures, or electronic signature without the electronic record protocol
- No documentation of intent to order services and procedures, including incomplete or missing signed orders or progress notes
It may seem ridiculous that a doctor’s bad handwriting can be to blame for you suffering a severe medical injury. Unfortunately, sloppy handwriting and illegible writing are responsible for too many medical errors. According to an article in Time, “Doctors’ sloppy handwriting kills more than 7,000 people annually, based on a report from the National Academies of Science’s Institute of Medicine (IOM).
According to an article published in the Journal of the Royal Society of Medicine, handwriting in 15% of medical case histories is illegible. Doctors may even have a hard time deciphering their own notes in a medical record. “Illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate doses which, in turn, can result in discomfort and death.”
Messy handwriting can require other providers to interpret the writing and try to figure out what the record says. This can lead to other types of medical errors caused by misinterpreting the wrong abbreviation or reading the wrong drug name.
Historically, medical records involved a lot of abbreviations, often for medical terms in Latin. However, the guidance now recommends against abbreviations because they can commonly be misunderstood, illegible, or cause medical errors.
The Institute for Safe Medication Practices (ISMP) compiles a list of error-prone abbreviations. According to the ISMP, “these abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications.”
There are more than 100 abbreviations that are on the “do not use” list. As an example, take q.i.d.; q.d.; and q1d.
- QD or q.d.: Q.D. is an abbreviation of quaque die, Latin for every day.
- QID or q.i.d., for quarter in die, Latin for 4 times a day.
- Q1D or q1d: for one time a day, quaque 1 die.
For example, if a doctor prescribed a powerful medication to be taken one time a day but a nurse administered the drug 4 times a day, it could cause serious injury or death.
Another example involves using decimals. If a doctor writes a prescription for 1.0 mg of X, if the decimal is very light or not seen, another doctor could interpret the prescription as 10 mg, which is 10 times higher a dose than intended. Similarly, .5 milligrams could easily be misread as 5 milligrams. The recommendations are not to use a 0 trailing a decimal (1 mg instead of 1.0 mg) and to use a 0 before a decimal point (0.5 mg instead of .5mg).
Drug Name Confusion
There are hundreds of drugs that are commonly prescribed in hospitals and doctor’s offices. However, there are many drug names that look or sound similar to other drugs. Messy handwriting or not paying attention when reviewing medical documentation can cause serious injury when it causes confusion about the drug’s name.
According to the World Health Organization (WHO), look-alike and sound-alike (LASA) medication names are a common cause of medical errors. In 2004 alone, there were more than 33,000 trademarked medication names reported in the U.S. The ISMP has a list of medication name pairs that can be mistaken and has recommended changes to help reduce the risk of LASA medication errors.
A few examples of look-alike/sound-alike drug names include:
Wrong medication errors can be dangerous, including causing adverse interaction injuries, overdose, or failure to treat the patient’s actual condition with the right medication. An experienced medical malpractice attorney and their medical experts can review medical records to identify possible drug mix-up errors.
Another cause of documentation injuries involves transcription errors. Transcription errors can be a type of data entry error, where the wrong information is documented or there is a change from the correct information. For example, if writing down a long number, such as a patient’s ID number, getting the wrong number or transposing numbers can cause a wrong patient error.
One source of medical transcription errors involves the use of outside transcription services. Some doctors, hospitals, and diagnostic providers outsource medical record documentation to medical transcription companies. Some of these medical transcription companies use transcriptionists outside the country who generally don’t have any medical training and may not have English as their first language.
Electronic Health Record Errors
Most medical documentation is now done electronically. Moving away from paper records to electronic health records is a way to avoid some of the medical documentation errors, like illegible handwriting. However, there are other documentation errors that can happen when relying on electronic health record systems.
Just because a medical record is in electronic form does not necessarily mean that it is accurate. There can still be problems like transcription errors or lack of documentation when using an electronic health record (EHR). Many doctors feel overwhelmed by the amount of time it takes to document medical information using electronic systems when they could have done the same thing in a written form much faster. This can lead to fatigue and some doctors may put off e-documenting until later, when they may have forgotten some of the important information.
Identifying Medical Documentation Errors in Your Medical Record
If you’ve ever requested a copy of your medical records, you know how extensive they are. Even an overnight stay in the hospital may result in hundreds of pages of medical records. After a medical injury, there may be thousands of pages of medical records to review. How are you supposed to identify what went wrong in all those pages?
It can be very difficult for an average person to be able to find a needle in the haystack that shows what went wrong in your medical care. This is why medical malpractice lawyers often use medical experts to review medical records to find out what went wrong. Medical experts in a malpractice case are generally doctors who have experience in a similar practice area. They are familiar with medical records, standard practices, and documentation requirements. They can identify problems with your care just from the records and include this information in their expert report.
Medical malpractice cases have different standards than other types of personal injury claims. In a personal injury case, the injury victim has to show the defendant was negligent because they breached a duty of care to the plaintiff.
In a medical malpractice case, the case is based on professional negligence. The duty of care depends on medical standards for a doctor in a similar situation. This is why malpractice cases usually require a medical expert to testify to what the medical standards of care say about a given situation and whether the doctor committed professional negligence. If you have questions about how a medical expert will be involved in your case, talk to your medical malpractice attorney.
Can I Get a Professional Review of My Medical Records for Documentation Errors?
Doctor burnout can contribute to documentation mistakes. Many doctors are pressured to increase their patient load, giving less time to individual patients and requiring more time spent entering medical records and administrative medical insurance tasks. According to a survey in the Annals of Surgery, a majority of doctors who reported major medical errors attributed them to problems like fatigue or stress.
If you think you may have been injured because of a medical error, talk to an experienced legal team for advice. A medical malpractice lawsuit can help you recover compensation for your losses. Compensation in a medical malpractice claim can include money for medical bills, loss of income, and pain and suffering. A malpractice claim can also help others avoid similar injuries.
Experienced medical malpractice lawyers, like the trial attorneys at Gilman & Bedigian, have extensive experience in malpractice claims because they focus on just these types of cases. With the right legal team on your side, you will have the resources to help you recover damages after suffering a documentation error injury. Contact Gilman & Bedigian online or at 800-529-6162 for a free consultation.