Patient history and patient records are crucial for doctors to provide the best care. When physicians and medical staff do not record patient history or fail to take it into account when seeing a patient, the results can be disastrous. It happens all too often, and in fact a recent study found that, over five years, nearly 2,000 patient deaths were related to communication errors, accounting for nearly a third of malpractice cases.

Doctors need to include patient history in decision making because it informs the diagnosis they give and the treatments they chose to best help the patient. If you feel you suffered because your doctor disregarded your medical history or that someone made a mistake in recording your history, you could have a malpractice case. Let a malpractice lawyer help you make that case for compensation.

Errors in Patient History

Mistakes with medical history can take several forms, and may include mistakes made by the patient as well as medical professionals. Medical office staff may make errors in transcribing records or using codes to identify diagnoses, procedures, and treatment. Doctors and nurses may make mistakes as well when recording what patients are saying about symptoms and history, or they simply may fail to record these things at all. Patients may fail to include all of their medical history, such as medications they are on or past illnesses.

Physicians may make the mistake of disregarding a patient’s medical history, even if all the correct information is available. The doctor may simply ignore the records or may fail to request records from a previous medical office. In either case the physician puts the patient at risk by not having all the information needed to make good decisions about care.

Patient History and Negligence

Any action or inaction on the part of a physician or other medical staff that constitutes a breach in duty of care and causes harm and significant damages to the patient may be considered negligence and may lead to a successful medical malpractice case. In instances that involve the patient’s record and medical history, it must be proven that there was a duty of care between the doctor or medical facility and the patient. The case must then prove that the mistake constituted a breach in care, that it resulted in harm to the patient, and that the harm caused damages.

Each case is different, but generally if a medical professional does not do what a similar professional would have done in the same situation with regards to a patient’s records, it could be considered malpractice. The person who was negligent may be the physician, but it could be someone else. For instance, in one unfortunate case in which a patient died as a result, a nurse failed to tell a surgeon that the patient had signs of internal bleeding. The surgeon in this case did not intentionally disregard patient records of symptoms, but the nurse was the one to make the possibly negligent mistake.

The Consequences of Mistakes with Patient Records

The consequences of making errors in patient records and by ignoring or disregarding them can be very serious. These mistakes can lead to a failure to diagnose a patient correctly, errors in medications, and failure to provide the best treatment. These in turn may lead to ongoing symptoms, worsening illnesses, additional illnesses, a need for more treatments and more invasive treatments, additional medical bills and expenses, loss of wages, pain and suffering, and many more potential consequences. Malpractice cases can potentially provide compensation to help provide coverage for medical bills and the less tangible suffering patients experience because of preventable errors.

Examples of Cases Involving Patient History and Records

Many medical malpractice cases involve patient medical history or patient records. Physicians and other medical professionals have a responsibility to maintain good records and to take patient history into account when diagnosing and treating them. When this breaks down, the consequences can lead to malpractice cases that prove negligence.

In one of these cases, in which the patient won a $450,000 settlement, she suffered a stroke that was not diagnosed because a physician ignored her medical history. She showed signs of palsy in her face and a CT scan did not show evidence of a stroke, but her history included a heart valve replacement and prescribed blood thinners that she had not been taking. The patient provided this information, but by ignoring it, the doctor ultimately failed to diagnose the stroke and she suffered damage by not getting the right treatment sooner.

In another case a patient in an emergency room was given doxycycline for treatment. It triggered a reaction called Stevens-Johnson syndrome. The syndrome is a painful skin reaction that requires emergency treatment. The ER doctor failed to get and look over the patient’s records from a regular doctor, which included information that would have precluded the use of doxycycline. The patient started a malpractice case because the treating doctor failed to obtain patient records and use medical history to make the right treatment choices.

Another case involved a patient whose first language was not English. The Cantonese-speaking patient was being treated with chemotherapy for cancer and was given the wrong dose. The too-high dose caused serious damage after a toxic reaction. The medical records for the patient failed to note that he needed a translator. Doctors instead relied on the patient’s son to translate, and this posed concerns for accuracy and ethics, not to mention confidentiality. The patient proved his case of malpractice related to records successfully and got a settlement of $105,000.

Patient medical history is a crucial part of diagnosing, treating, and providing the best possible standard of care. When medical history is ignored, when records are not taken, or when other mistakes occur with communicating patient history, symptoms, and other factors, patients suffer. The consequences may range from mild additional symptoms because of delay in treatment to extreme suffering and death that could have been prevented. If you have been the victim of a mistake made with your records or a blatant disregard for your medical history, find out if you have a case for medical malpractice.