Posted by Bill Sandweg on 12 October 2020.
I am sure most of you remember the children’s game of Telephone. You get a group of people and the first tells a secret to the second. The second repeats the secret to the third person, who tells it to the fourth and so on until everyone has been told. Then you compare the secret the first person told with what the last person was told. There is almost always a big difference. The message gets garbled and mangled as it goes from person to person. Like it or not, the game of Telephone accurately describes what happens in your medical records.
In the course of my practice, I read a lot of medical records. It is the rare case in which I fail to find some significant mistake. My client may be seeking compensation for the results of a head injury resulting from an accident in May. Her records may say that she has been experiencing the effects of a head injury since March, two months before the accident. The timing of the onset of problems is one of the most common errors I see. Another common error is the patient who is having problems at the time of the office visit but they are not mentioned in the chart. Needless to say, the defense jumps on these mistakes and uses them to weaken my client’s case.
Your medical records are like the game of Telephone because, once an error appears, it is repeated over and over. Sometimes, it gets worse, as the mistake becomes even more egregious, but it never gets better. So how do medical records get corrupted in the first place?
The first part of any medical encounter should be a patient history. It should be careful, thorough and accurate. It should address not only the chief complaint which brings the patient to the encounter but events which have occurred in the past, which may be relevant to diagnosis and treatment.
Unfortunately, due to the economic realities of running a medical office today, it is rarely the doctor who takes the history. It is usually taken by an member of the doctor’s office staff. That person is never going to be as well-trained as the doctor. The staff member may be well-trained and experienced or may have just started last week. That person is almost never going to understand the significance of every event in the patient’s history. That person is not usually going to know what questions to ask to draw out additional relevant information from the patient.
The office person taking the history is not going to write down everything the patient says. The staff member is usually busy with a number of duties and will usually write down only what seems important to them. That may or may not be what is actually the most important information for this particular encounter.
Many staff members will look at the patient’s chart and just ask if there have been any changes since the patient last saw the doctor. If the answer is no, the staff member may just cut and paste the history from the last visit, which may itself just be a copy of the history from the visit before that. I see these word-for-word histories repeated, sometimes even over a course of years. Once an error is made, it gets repeated over and over.
Errors which appear in your history may affect the treatment you receive from the doctor. The doctor may not go over all the history with you on his or her own. She or he may simply accept the history taken by the staff member.
Errors which appear in your history may affect legal claims you bring. As I noted above, an error in your records can undermine your claim in a number of different ways. The defense may argue, for example, that you could not have been severely injured because you didn’t tell the doctor about the problems you are now claiming. It won’t do you much good to point out that you did tell the office staff but they must have failed to note it in the records. Juries tend to treat medical records as the Bible. If it is in the records, it is true. If it is not in the records, it didn’t happen.
All this means that you should be proactive about the quality of your medical records. You have the right to see your records and the right to insist that erroneous information be removed or otherwise corrected. You may not find your doctor or the doctor’s office all that willing to accommodate you in making changes, but you should at least make the effort. If they refuse to make the changes you believe are necessary, write up your version of the facts and ask them to place it in your chart. For a whole host of reasons, it is better to do this sooner than later, so get over to the offices of your doctors and see what they have been saying about you.