Medical records may hurt you in court

The medical record may be less reliable than we think it is. Anyone who contacts a patient can write in their record. Such people could include physicians with 30 years of experience and second-year medical students experiencing their first medical clinic.

This situation is problematic because most often those who have been supervising a new physician will not make changes in the record, even if they disagree with what was written. A supervisor may even cosign a note without reading it. In addition, occasionally someone who does not read a previous entry makes new entry. This is a common problem that often becomes one of the main issues in a lawsuit.

As an expert witness or defendant, be sure that you know what has been written in the record and also the dynamics that affect the accuracy of the multiple notes. This information should help you explain discrepancies that might be brought up in court.

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Reed Tinsley, CPA