The Truth Is No Longer In The Medical Records

Reviewing medical recordsOnce upon a time. . . we relied upon the medical record to tell us the non-fiction version of what happened to our clients. Then along came electronic medical records and non-fiction is no longer fact.

The medical record is supposed to be a systematic documentation of the medical care across a defined period of time. The components of the record include health care providers’ pertinent observations, administration of drugs and treatments, test results and radiology reports. In the past, when hand written paper medical records were the norm, the content of the records included a time that reflected the occurrence of the significant events. Most importantly, the process of creating the records required concentrated reflection of the provider. Taking pen to paper was tedious but it forced a certain amount of focus on the patient whose records were before you. Furthermore, when we requested the paper medical records, we received copies of what the health care provider actually had available to her during the time period that care was provided.

Contrast this with the electronic medical record. For the most part, electronic medical records are not created by health care providers. Far removed from the clinical setting, the content of templates and drop down menus are predetermined by large vendor corporations whose focus is often billing and not standard of care medical practice.  Independent thought has been replaced by robotic checking of boxes. To add insult to injury, the use of the copy-and-paste function creates potential risks to the very integrity of the medical record. See; “Preventing copy-and-paste errors in EHRs”, Quick Safety, Issue 10, February 2015-Joint Commission.

I constantly hear complaints by health care providers regarding electronic medical records. The most common universal complaint that I hear is that they are limited in their ability to include what they believe is important. Self populated records automatically fill in a complete physical exam with a simple check mark made in a box. The content that is recorded reflects examinations that were not even performed. Critically important is the fact that the electronic medical record does not mirror the reality of the patient’s medical condition and actually contains false information. In addition, depending on the electronic medical record system, the time reflected in the record is often the time the care was recorded, not provided, leading to a quandary when trying to establish an accurate timeline of care.

The current reality in medical malpractice is that when we request copies of the electronic medical records, we do not receive anything that even remotely resembles what the health care provider had available during the time period that care was provided. What we receive is at best, incomplete information and at worse, inaccurate information.

It is an unfortunate fact that the implementation of electronic medical records have not only made our jobs of finding the truth more difficult, but tragically, they have dumbed down and effectively removed the independent thought process of health care providers that is vital to the delivery of quality medical treatment.

If you have been the victim of medical malpractice, seek the counsel of an experienced attorney.

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