The importance of keeping accurate and timely medical records

Recently, a Brevard County, FL, jury returned a verdict of $7.5 million against a pediatrician who neglected to tell a mother or other doctors that her daughter had a dangerous heart condition which later killed her (Rowe v. Wickham Pediatrics/Dr. Agha).

The circumstances surrounding this incident highlights a breach of a doctor’s duty of care to his or her patient where there was an omission to maintain an accurate record of treatment provided to the patient and subsequent failure to diagnose a dangerous cardiac condition.

Medical records are central to all patient healthcare activities. Fundamentally, they form part of a doctor’s ethical and statutory duty in providing good patient care.

A patient’s medical record will likely include any handwritten clinical notes, emails, scanned records, consent forms, text messages, verbal correspondence between health professionals, medico legal reports, referral letters, investigation reports, laboratory results, X ray films, photographs, video and audio recording and any printouts from monitoring equipment.

Medical records also represent the patient’s medical, health or social history, diagnosis, condition, treatment or assessment, created or maintained by a doctor or other healthcare professional, or a hospital or other health facility.

Good quality medical records are essential to proper ongoing care of the patient and are paramount for effective communication between healthcare professionals and their patients.

A patient’s medical record should be continuously updated in chronological order so as to demonstrate continuity of care and response to treatment. The information should be comprehensive enough to allow a colleague to carry on where the previous clinician left off.

In Australia, a medical practitioner has an ethical and statutory obligation to maintain accurate, contemporaneous records of treatment provided to their patients. An expression of this obligation can be found in Regulation 5 of the Health Insurance (Professional Services Review) Regulations 1999 (Cth)

For the definition of adequate and contemporaneous records in section 81 of the Act, the standard to be met in order that a record of service rendered or initiated be adequate is that:
(a). the record clearly identify the name of the patient; and
(b). the record contain a separate entry for each attendance by the patient for a service and the date on which the service was rendered or initiated; and
(c). each entry provide clinical information adequate to explain the type of service rendered or initiated; and
(d). each entry be sufficiently comprehensible that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care.

Importantly a patient’s medical record constitutes a legal document which records events and decisions that help the practitioner manage patient care. A medical record can be the single most important evidence for the healthcare practitioner in lawsuits, hearings or inquests, or when patient care provided by the practitioner is in question.

Failure to keep comprehensive medical records may ultimately compromise ongoing care and management of the patient. The circumstance surrounding the above case clearly demonstrates the failure of adequate record keeping skills. In the above case, the Pediatrician and ER doctor failed to document important information in the patient’s medical record that ultimately led to a catastrophic outcome.

On the facts at hand, the child’s mother brought her daughter to the ER after suffering a heart seizure. The ER doctor examined the child, an EKG was undertaken and the child was then referred to a Pediatrician. Following the abnormal EKG, the ER doctor telephoned the Pediatrician and advised her that he was sending the patient back for follow up of an abnormal EKG.

Evidence presented in this case indicated that the ER doctor failed to inform the child’s mother of the abnormal result. The child was therefore referred back to the Paediatrician (who allegedly was unaware of an abnormal EKG result) who then referred the child to a paediatric neurologist for further management. The lack of disseminating vital information meant that that the child’s cardiac condition was not diagnosed.

During testimony, the Pediatrician indicated that she recalled her conversation with the ER doctor but did not recall anything in relation to the abnormal EKG. Unfortunately in this case, both doctors failed to record the contents of their telephone conversation in the patient’s medical records.
Undeniably, the ER is generally considered as a frenetic, chaotic unit. The ER is usually brimming with patients (and their families), orderlies, security staff, administrative staff, nurses, doctors and other allied healthcare professionals.

A close look at the facts of the above case should prompt any prudent lawyer to carry out a thorough investigation. Investigations would involve careful scrutiny of the medical records, obtain rosters of all staff who had worked in the unit on the particular day and question witnesses.

In the above case, the ER doctor, the assistant to the ER doctor and Pediatrician all testified. During the trial, the assistant to the ER doctor’s physician testified that she overheard a telephone conversation between the ER doctor and the Pediatrician in relation to the findings of an abnormal EKG. The Pediatrician admitted that she recalled the conversation between herself and the ER doctor, but denied that she had mentioned anything to him about an abnormal EKG.

Even though both the ER doctor and the Pediatrician failed to note the contents of the telephone conversation in the patient’s medical records, the jury preferred the ER doctor’s testimony from that of the Pediatrician’s testimony. Thus, the weight of evidence concerning the telephone conversation that was overheard by the ER’s assistant was the linchpin in this case.

Ultimately, the above case clearly demonstrated the necessity for all healthcare professionals to ensure they keep accurate, timely and clear medical records. Inaccuracies or improper record keeping may have devastating consequences to the patient and all concerned in the care of the patient.