Doctors Make Mistakes with Medical Records
To err is human … sometimes patients can make mistakes while in pain or when seeking urgent medical treatment. The same is true for medical professionals who work in high stress conditions attempting to treat a suffering patient. These mistakes can happen before, during or even after care is provided by way of noting errors in a patient’s medical records. Busy intake nurses may notate an incorrect accident date or omit ancillary injuries to the purpose of treatment Scribes may record inaccurate information given to them by the treating provider. Translators can easily provide the wrong information since many words and concepts can be problematic for the healthcare worker.
Even when they might translate well, there can be vast differences in the abilities of the available translators. For example, how many ways can a person describe a painful sensation in English: visceral, stabbing, stinging, burning, splitting, crushing, gnawing, pulsing, nagging, gripping, deep, scalding, shooting, throbbing, sharp, dull, radiating, recurring, intermittent, chronic, acute and so on? A translator may end up describing that something simply “doesn’t feel right.”
Unfortunately, this leads to numerous incidents of a person’s medical records containing inaccuracies. Doctors are well aware of this problem. There have even been cases where a surgeon operates on the wrong body part due to mistaken medical notations. If a person has hundreds of pages of medical records, there will undoubtedly be various typos, misstatements and other inaccuracies that are just part of what’s expected.
What Are Your Options For Correcting Your Medical Records?
Errors in medical records are a well-known and ubiquitous phenomenon. The Washington State Legislature has acted to provide a little-known mechanism by which patients may request corrections or amendments. Pursuant to RCW 70.02.100, a patient may request correction or amendment of a medical record “for purposes of accuracy or completeness.” The patient should write to the medical provider and identify the error in the record while also asking for a change or amendment. The medical provider then has ten (10) days to inform the patient that they have changed the record, or that they have decided not to change the record for whatever reason they have. Nevertheless, the request for change, correction or addendum also becomes part of the medical record so that there remains proof that the patient disagrees with what has been stated.
Most people don’t realize that their medical records may contain errors that ultimately result in problems for the patient. Defense attorneys search medical records for the errors and omissions because they are expected to exist there. They will then attempt to paint the patient as an inaccurate historian, non-credible claimant or plaintiff, or worse. Defense medical examiners, often called Independent Medical Examiners, testify that all they can go on is the information that was recorded in the file. The unfortunate result can be a misrepresentation of the patient’s injuries or the patient’s need for the particular medical treatment being sought out under the claim or suit.
Some damage is already done once an error is made but if a patient acts to review (although most don’t) and asks for corrections or addendums to their medical records in a timely fashion, the damage can be minimized. For this reason, if you have a personal injury, workers’ compensation or another type of suit or claim that depends on what is recorded in your medical records, it’s best to regularly ask your doctors for a copy of those records so you can review them before too much time has passed.
Legal Assistance Reviewing and Correcting Your Medical Records
If you have questions during this time or need help reviewing your records from the standpoint of the law, contact the experienced trial attorneys at Washington Law Center today.
ABOUT THE AUTHOR:
Spencer Parr is a litigation and trial attorney at Washington Law Center focused primarily in the areas of Labor & Industries claims and injury pension benefits. Before co-founding Washington Law Center, Spencer served in the U.S. Army. He has litigated major issues in the law, represented clients from coast to coast, and dedicated his professional life to assisting the injured and disabled. Click here to learn more about Spencer. View More Labor & Industries and Work Injury Resources.