The Importance of Accurate Medical Records

Not only is it important for medical reasons that a patient provides accurate information to a treating physician, it is important from a legal standpoint that medical records contain accurate information. It is not a very frequent occurrence, but occasionally we see records of a person who suffered a major injury, and some additional minor injuries, that reflect that the patient completely failed to report to the physician who sees them in follow-up to an emergency room visit, anything other than the major injury. Usually this will happen where the follow-up treatment is to a physician with expertise in orthopedic injuries, and the patient also has an eye injury or an injury in some other area of the body with which the specialist being visited does not deal. If in such a situation, the patient is shown a drawing of a person and asked to mark all areas where pain is being felt, the patient should rightly mark pain in the eye or head region of the body, as well as pain in the back or neck or other area with which the orthopedic specialist is expected to deal. To neglect to mark all areas of pain not only may impact medical care (such as being prescribed medicine that may help your back, but make the eye worse), it can create an inaccurate record that an opposing attorney can exploit and ask “well you say your eye continuously gave you pain for weeks, but when you saw Dr. X and were asked to mark all areas of pain, you did not mark that your eye was giving you pain, did you”?