Common Mistakes in Medical Records that Harm Your Injury Case

Medical record errors in your injury case could be detrimental to the outcome of your lawsuit. Sadly, it is a normal occurrence that medical records contain inaccurate or misleading information. Sometimes, there remain significant omissions that interfere with your case. Therefore, it is crucial that you are aware of which problems might arise with your medical records, and what to do to prevent them from occurring.

Errors at the Emergency Level

When you receive emergency medical care, all things are done immediately. If you are incapable of speaking or communicating, physicians might add information to your chart as they understand it from eyewitnesses or first responders at the scene. For example, say that you are injured in an automobile collision. But, you cannot show what hurts because you are unconscious. In this scenario, a critical injury might be missed.

ER doctors and paramedics are trained to understand an injury’s technical aspects, but not necessarily how it occurred. A doctor only needs to understand why you are injured but does not necessarily need to know what caused each injury. For example, a doctor may know that you were injured in an automobile collision but is not concerned with which aspect of the accident caused your broken femur.

Errors in Follow-Up Care

Errors in medical records during follow-up care and treatments are plausible. These medical errors can often more problematic than those that occur in emergency room care. During follow-up treatment, you are conversing with your physician and often the physician will dictate his visit notes after hours or between patients. You must be proactive when speaking with your doctor to ensure that he or she inputs the correct information.

Tips for Avoiding Errors in Your Medical Records

  1. Be Clear About Concerns – When conversing with your physician, be clear about any medical concerns you might have. Ensure that those concerns are noted accurately. If you have pain on your right side, you must ensure that the pain is documented accordingly.– and make sure that you note which side the pain is on whenever you are given forms to complete.
  2. Seek Medical Treatment Immediately – Seeking medical treatment shortly after the accident is critical. This is the beginning of a proper medical chart, which is needed to prove your injuries accurately. If you sought emergency treatment, follow up with your regular physician as soon as possible, as well.
  3. Ask to Review Your Chart – You have the right to review information as it is inputted into your medical chart. So, perhaps with the nurse you meet with at the beginning of your appointment, request a brief review to ensure everything is accurate. (It is best however, that you do NOT discuss that you are doing this because you have a claim pending. You are doing this because the best care is based on accurate information!)
  4. Discuss All Symptoms – Even minor symptoms should be placed in your chart, because these might escalate into significant issues later. For instance, by starting documentation early which shows when you first starting having complaint of issues with your shoulder, the records will assist six months down the line when it comes time to prove that your rotator cuff tear that shows up on an mri is related to the accident. The notation of pain dating back to the accident helps to prove the injury is caused by the accident, even though the diagnosis wasn’t made until the mri was done. “Gaps” in treatment are all too often a line of defense for insurance companies– sometimes even a gap of a couple of weeks. So don’t wait to call your doctor– a “wait and see” approach may not be what is best for your health or your case!

Get Assistance with Your Personal Injury Case

After a major injury, speak with a personal injury attorney as promptly as possible. An attorney will find the red flags in your medical records and do what can be done to correct the information and keep it from getting in the way of compensation for your injury. Speak with an attorney from Jacobs Law, LLC today by calling our office or connecting with an attorney online.