Medical records have always been a key element in the preparation and proof of a medical malpractice case in Oregon and all other jurisdictions. Those records now consist of electronic data as opposed to the old-fashioned kind of hard copy typed transcripts. The electronic aspects of the records can cause problems for the litigants in some instances, including the typically unending problem of trying to locate all of the records and organize them in a sensible compilation. Leaving that issue aside, the medical records can in some instances be a major tool in proving hospital negligence sufficient to establish a valid claim for the patient.
Medical records sometimes turn out to be the key piece of evidence in convincing the fact-finder to enter an award, or in pressuring the defense into a settlement. That is generally because medical providers and medical personnel tend to sometimes unknowingly spell out the details of the defendant's negligence. Thus, in their descriptions of surgical procedures, medication protocol, emergency room foul-ups, and the like, the basic case may be simply and powerfully established for the plaintiff.
Some problems that defendants create and face include time-stamp manipulations, attempts to change or modify entries after-the-fact, template answers, autofill problems and the failure to enter comment where it would be explanatory. Furthermore, when doctors try to make changes in medical records they may be unaware that these entries are now subject to being tracked and identified. Another problem is the automatic template program some hospitals use to save time in producing medical records.
These automatic entries will get out of sync with the actual facts of the case in some instances, so that inapplicable events and conditions will be reported, thus causing suspicion, and at least a lack of credibility of the records. The problems exist in Oregon as well as throughout the country. For plaintiff's counsel, obtaining and examining the medical records is the most important initial task to be accomplished in the process of determining whether a case of hospital negligence or physician malpractice exists.
Source: businessinsurance.com, "Malpractice suits often tap electronic medical records", Judy Greenwald, Oct. 27, 2014