David Cohen at the Nursing Home Lawyer Blog recently wrote how sloppy medical records have a disastrous impact on patient care— I couldn’t agree more. In nursing home litigation, records play a crucial role in determining who did what, when. As lawyers we must work backward to determine why happened to our clients. Perhaps a better characterization would be that we try to determine what may have happened to our clients. If medical charts are littered with vague notation, absent notation, or perhaps most common–sloppy penmanship–our jobs become difficult. At some points we must fill in the blanks.
In many nursing home litigation cases, we will order medical charts several times–not because we are tree killers–but to assure clients that we are working with a complete set of records. Invariably, each set of records is different. Pages or even complete sections may be included in one set only be missing from another.
Unlike most areas of the law, reviewing sloppy medical charts does not get any easier with practice. Too often I receive stacks of medical records from a nursing home or hospital, and desperately try to decipher the cryptic penmanship of an attending nurse or physician. The reality likely is, that although I may get frustrated when I can’t read the scribbled notes on page after page of medical records, a nurse or other nursing home employee probably also tried to decipher the abstract code with the same lack of success that I did.
Nurses and physicians will attest to the importance of keeping detailed and accurate medical charts is essential in providing quality care. What happens when a nursing home employee is presented with a medical chart containing gaps, scribbles and missing pages when making a medical decision? If a nurse can’t read an order, how can the order be implemented?
No doubt about it, frequent errors are made, not necessarily due to a lapse in medical judgment or mistake when performing a complex task–but because of poor recordation and chart-keeping. As David points out, until nursing homes and hospitals make patient documentation a priority, there will be countless situations where sloppy record keeping will force nursing home workers to literally play a guessing game with respect to providing quality patient care.
Read more about the Nursing Homes Abuse Blog’s entry on the use of barcodes to prevent prescription errors here.