Are Charting Errors a Form of Medical Negligence?

Are charting errors a form of medical negligence

When you go to see the doctor or surgeon for a procedure or a health concern, you expect your records to be accurate and updated so that you can receive the best treatment for your health issue.

Sometimes, however, people make mistakes when inputting a patient’s health history or necessary tests, etc. Even small errors or omissions in a patient’s medical history can result in severe injuries and harm to a patient, so to answer the question, “Are charting errors a form of medical negligence?”

The quick answer is yes.

Let’s explore more about the seriousness of these errors and your available legal options if you’ve suffered harm due to a mistake like this.

Types of Charting Errors and the Problems They Cause

As patients, we expect our medical records to be accurate and complete, but what happens when someone makes a mistake and puts in the wrong information or forgets to enter something in the computer vital to our care?

Here are some of the most common charting errors and the issues that could arise because of them.

Incorrect Medical History

Having the wrong information in a patient’s medical record is an unfortunately common mistake.

While some errors are  minor and resolved quickly, others can be fatal. For example, if a patient arrives in an urgent care clinic complaining of chest pain or tightness and that information written down in the chart incorrectly, it could lead to a patient suffering cardiac arrest or other serious medical conditions that likely would not have occurred had the patient’s history been correctly input into their chart.

Not Documenting Important Information

This error goes hand in hand with the previous, but rather than inputting the wrong medical information entirely, this is about leaving out pertinent information or skipping steps in a patient’s health evaluation at intake.

It’s important that a patient’s chart is exact, which is why the following information should be correct and updated at every appointment:

  • Current vital signs
  • Physical examination
  • Chief complaints
  • History of illness
  • History of allergies
  • Surgical history
  • Obstetric history
  • Family history
  • Immunization history
  • Developmental history
  • Habits (including diet, exercise, alcohol or drug use, smoking, etc.)

All of this is important for proper patient care, especially if the patient has an emergent health concern.

If laboratory test results, for example, are not documented in a patient’s record, this could lead to a misdiagnosis or delayed diagnosis for the patient, which in turn could cause a life-threatening situation.

Documenting the Wrong Patient Information

Patient mix-ups happen. Nurses or medical staff might be overworked or handed a pile of charts with little explanation as to which patients they belong to and can easily write down the wrong symptoms or illness information in the wrong chart.

This can happen with digital charts as well. For example, if the previous patient record was left open and the nurse who comes in doesn’t double-check the date of birth or any other personal information, they may input the current patient’s health concerns into the previous patient’s record.

If one patient’s information is added to another patient’s record, this can lead to serious problems, such as one patient going in for exploratory surgery when what they needed was a lung X-ray or a patient being given a cancer diagnosis when they are cancer-free.

Inaccurate Medication Instructions

According to a study from the National Library of Medicine (NLM), 50% of medication errors are due to the wrong medication, wrong dosage, or wrong dosage frequency.

It’s vital to a patient’s safety that nurses and medical staff always double-check with the patient and their doctor what the patient’s symptoms and diagnosis are before prescribing or administering medication.

Additionally, there are medications that may sound similar but have very different effects or purposes, and if the patient is given the wrong medication or administered the wrong dose, this could lead to a severe or even life-threatening medical emergency.

Transcription Errors

Doctors use speech recognition software to make notes about patients, treatments, and diagnoses, but as we know, recording devices often pick up incorrect words or sounds.

If a doctor’s verbal notes are misunderstood by software, this could lead to the wrong word being recorded in a patient’s chart, and if those notes are never double-checked for errors, a patient’s health and sometimes their life could be on the line.

This is why it’s important for any medical professional using transcription software to check their notes before submitting them to a patient’s chart.

Abbreviation Mistakes

With the high workload and even higher stress level that come with working in a doctor’s office or hospital, nurses and doctors implement as many time-saving measures as they can.

In the case of medical abbreviations, however, the chances of misinterpretation are high. If one nurse misreads an abbreviation that the doctor put on a patient’s chart, it could lead to an incorrect dosage of medication or other harm befalling the patient.

As you can see, there are a number of ways that charting errors can occur, and if a mistake in your patient records leads to you suffering an injury, you may have grounds for filing a medical negligence claim. Your lawyer will have to prove that you were owed a duty of care, that the medical staff breached that duty by incorrectly handling your patient records, and that breach of duty led to the injury or illness you sustained.

These cases can quickly become quite complex, but an experienced Charleston medical malpractice who regularly takes on cases where charting errors were negligently made can help.

Our legal team at Hendrickson & Long, PLLC can do our best to ensure that your case is taken seriously and handled properly, including helping you recover a settlement for the wrongdoing you endured.