A typical feature of every hospital based medical malpractice case is the effort to track down when the doctors knew something and what they did or didn’t do in response to that knowledge. Proving a medical malpractice case requires two essential elements: a deviation from the applicable standard of care and a link between the deviation and the patient’s injury. In a hospital based case, proving a deviation often comes down to finding out what did the doctor reasonably know, and when did she know it. In the past, medical malpractice attorneys, faced with handwritten records, often had to rely on the faulty or self-serving memory of the doctor wrongdoers. Enter electronic charting and medical chart errors, and the balance began to be tipped in the patients favor.
Electronic medical records (EMR) are computer based data entry programs. While there are several different programs in wide use in American hospitals, they do share some essential features; among them is the permanent recording of who accessed the record, where in the hospital they were when the record was accessed, what data they accessed and for how long. Some have gone as far as to call electronic medical records “an electronic fingerprint with time included.”
Perhaps the case revolves around a critical piece of laboratory data-say a white blood count in a patient with a suspected infection. The claim may be that a nurse failed to report the lab results, or that a doctor failed to act on the nurses report. Or, the claim may be that the doctor missed the chance to access the available data. The EMR can shed light on these questions and many others.
At Simonson Hess Leibowitz & Goodman, we keep current with new technical developments, such as the tracking features of electronic medical records.