Medical errors are the third leading cause of death in the United States. A Johns Hopkins study found more than 250,000 people in the U.S. die every year from medical mistakes, making it the third-leading cause of death after heart disease and cancer. Other studies have found the number to be higher than 400,000 deaths annually.
Inaccurate medical records contribute to these errors. Even minor errors in records, a spelling mistake for example, can have consequences such as improper service coding and inaccurate billing. Though electronic health records (EHR) were meant to provide accurate and up-to-date information, mistakes still occur.
In the event of a medical malpractice lawsuit, medical records will be used to determine how and and why the healthcare professional made the medical error. Medical malpractice cases occur when a healthcare professional negligently causes an injury, or other damages to a patient, and the patient or their family files a claim.
Reviewing Medical Records for Errors
Medical records are a medical and legal document. By law, patients have the right to their records––including doctors’ notes––and the right to correct any errors. Reviewing records for accuracy is important and can lower risk of misdiagnosis, duplication of testing and procedures, inappropriate care, and even provide evidence of medical identity theft.
Medical records include information such as:
- Doctor and other provider’ notes about visits
- Laboratory test results
- Records kept by any testing centers, hospitals, or other facilities visited
- Information from the Medical Information Bureau (if such records exist)
- Insurance billings and codes
70 percent of patient records have incorrect or missing information, sociologist Ross Koppel, PhD, told CNBC. These mistakes can lead to adverse or even fatal results. For example, a physician could misdiagnose a patient based on faulty or incomplete records, fail to properly address any allergies, and provide unsuitable and potentially dangerous medication.
Common Medical Record Errors
Erroneous information
Whether records are paper or digital, it is possible for another patient’s information to erroneously be placed in a file. If this happens, a written request must be submitted to the physician, requesting the information be rectified. The physician then typically has 60 days to respond to a request.
Disorganization
The longer and more complex a medical history becomes the chances records may be missing or contain inaccurate information increases. This is especially true for those 65 and older. Reviewing records on a regular basis, including medication lists, lab test results, medical bills, and doctor reports for errors or missing information helps mitigate the risk of complications.
Diagnostic Errors
A diagnostic error occurs when a doctor or medical professional misses or delays proper treatment due to incorrect or false lab test findings. Diagnostic errors can result in delayed treatment, or the incorrect treatment of a patient, causing further health issues or even fatality. If diagnostic errors or incorrect lab results are found in a medical record, the record will be used to determine liability should injury or further illness occur.
Although definitive data isn’t available, the Office of the National Coordinator for Health Information Technology estimates nearly 1 in 10 people who access records online end up requesting they be corrected for a variety of reasons.
Requesting Records
In order to receive medical records, a request must be sent directly to the doctor or hospital. Physicians and hospitals are required to respond in writing within 60 days, with the possibility of a 30-day extension, although some states mandate shorter deadlines.
Medical providers are not obligated to accept requests to change records. For example, if a doctor notes in a file that the patient is a possible drug seeker, and the patient requests the note be removed, the doctor may deny the request. If the doctor rejects the request, the patient has the right to add another statement contesting this decision. The patient also has the right to file a complaint with the government office overseeing HIPAA or the state agency licensing physicians.
Let Us Evaluate Your Case
If you or a loved one has been injured due to medical malpractice stemming from inaccurate medical records, the experienced legal team at Miller & Wagner is prepared to help you build a case. For more information on filing a claim in the State of Oregon, get in touch with one of our medical malpractice lawyers today.