A significant percentage of medical errors stem from poor record-keeping. Physicians and hospitals should have reliable documentation practices to prevent such errors.
Here is how poor record-keeping can lead to medical malpractice:
Missed/delayed diagnosis
If a physician records a patient’s symptoms incorrectly, perhaps they fail to write down a symptom or a condition a patient outlines, the chances of missed or delayed diagnosis can be high.
Ineffective treatment plan
Before a patient is treated, doctors typically assess several treatment plans to choose an effective one. A patient’s condition and medical history usually help them make this choice. And this is where poor record-keeping can have a negative effect. If a patient’s medical history is poorly documented, doctors may administer a treatment or medications that do not work.
Doctors may even give a patient medication they are allergic to if their medical history is recorded incorrectly.
Further, even a mistake that seems simple, such as a misspelling, can deny a patient proper treatment, especially when several physicians are involved, for example, in the case of a referral.
Treating the wrong patient
Poor record-keeping is one the leading causes of wrong-site, wrong-procedure and wrong-patient surgery. A surgeon can mix up two patients if they have records that are not well documented or organized.
Poor future treatment plans
When a hospital or physician serves a patient, they should record every detail, including diagnoses, treatment plans, medications, allergies, examinations, recovery plans and so on. Any doctor who treats them in the future should be adequately informed by going through their medical history. If a hospital or doctor fails to complete a patient’s medical history, they may face difficulties during future treatments.
If you have experienced medical malpractice due to poor record-keeping, seek legal guidance to protect your rights.