As a patient, you provide information a health care professional needs, such as the medicines you take and the kinds of allergies you have. Information like this should be entered into your medical record along with any updates.
If the information is not complete, or if there are inaccuracies, your health might be adversely affected. If this should happen, you could have a claim for medical malpractice.
Proper recording practices
To avoid overlooking any information a patient provides about medications and allergies, health care professionals can flag both traditional and digital charts using a colored sticker or a special digital symbol. If a patient reports no known drug allergies, “NKDA” should be noted in the record to verify that they asked question. Health care professionals should also note the names of any other doctors treating the patient along with the conditions and medications they are managing. As to medical conditions, health care providers should always record dates of onset, ongoing treatment and resolution. A problem list would show medical conditions and who was treating the patient so that treatment by other health care colleagues could be coordinated properly.
Medical records and litigation
Along with risks to patient safety, the accuracy, completeness and even legibility of medical records have considerable bearing on the outcome of litigation. It is not unusual for the plaintiff to prevail in a court action that centers around the poor quality of record keeping. Any doctor who has had to spend time in meetings with legal counsel, depositions and preparations for trial will acknowledge the prudence of keeping more accurate documentation on patients.
Results of poor charting
If you are allergic to penicillin, for example, but were given this medication during a hospital visit, it may have seriously affected your breathing. Perhaps complications followed and you needed further medical treatment simply because the allergy was not properly noted on your chart. Records omissions or inaccuracies that result in patient safety issues raise red flags that may signal the need for legal counsel and the possibility of a medical malpractice suit.