Incomplete medical records

The attorney reviewing a medical record finds that there is no documentation that describes what a healthcare provider did. What are some possible explanations? Attorneys like to use the phrase “If you didn’t chart it, you didn’t do it” to focus on missing documentation. There may be other explanations.

1. The page describing the care was not supplied by the medical records department or healthcare provider.
Solution: Ask for a certified copy. Look at the original if necessary. Consider the possibility that the page describing the care was removed from the medical record.

2. It may have been done but the provider forgot to chart it, was too busy or distracted.
Solution: Ask the provider if he or she has any memory of doing it. Recognize that memories are flawed or may be influenced by self-serving needs. The provider will assert that although it was not charted, it was his customary practice to do a specific thing. It is not possible to document every single element of care.

3. The care in question may be documented by someone else in the medical record.
Solution: Carefully review the medical record to see if the care is referenced by another provider or if orders were written based on the care. Sometimes a timeline helps to more clearly define the details.

4. The care was not done. The provider cannot effectively assert that he or she did something in the absence of any documentation that verifies that it was done.
Solution: Look at the implications of the absence of care. Does it affect liability? Does it affect damages? Does it affect causation? Does it make a difference in the case?

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Need help figuring out how an error occurred? Our legal nurse consultants work with medical records and attorneys to create chronologies, develop questions for depositions of defendants and suggest items obtain through discovery. Give us a call. We’re here to help.