With the advent of electronic medical records in Oregon and all other states, doctors now have the duty to put certain information into the patient's digital record so that it will be there for future use by doctors and hospitals. A case in another state shows that failing to enter the required data can be considered medical malpractice. A jury recently awarded $35.4 million to a woman who suffered a stroke and became paralyzed after giving birth because certain information was not inserted in her record.

The woman, a former teacher, went to the defendant doctor and medical group in 2004 after having dizzy spells. The defendant doctor ran tests and found certain brain abnormalities that by normal protocol are required to be entered in the patient's digital medical chart. The doctor failed to do that.

When the woman went to deliver a baby some years later, there was no mention of the brain problems in the patient's records. If the information had been there, she would have delivered by a Cesarean operation because her brain deficiencies made it dangerous for her to be in labor. She was allowed to deliver without the Cesarean, and within hours of the birth, she suffered a massive stroke that left her paralyzed.

She now needs 24-hour care, which will be covered by the jury's verdict. The baby girl was born normal, but the mother has limited abilities to care for her and communicate with her. The verdict covers past medical expenses, future expenses, lost earnings and earning capacity, and pain and suffering.

The theory of negligence is simply that the doctor failed to follow an established protocol that requires brain irregularities like the patient's to be entered in the database. The failure to do so resulted in precisely the kind of tragic results that were intended to be prevented. The case signifies the emergence of a new kind of medical malpractice case based on the opportunities for better health care opened up by technological advances in record-keeping. The principles of negligence involved in this case are also applicable in Oregon.

Source: The Boston Globe, "Walpole woman awarded $35.4 million in medical malpractice case", Travis Andersen, May 8, 2015