Medical records must be accurate and timely. Timeliness of documentation means that all entries should be made as they occur or as soon as possible afterward. Federal reimbursement guidelines mandate that all medical records should be completed within 30 days following the patient’s discharge from a hospital. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an agency that oversees hospital accreditation standards, also has issued guidelines for timeliness in charting.
Late entries into the medical chart mean that, even for a brief period of time, the medical record is incomplete. This can cause a serious problem if the incomplete record is subpoenaed for a malpractice suit. Any entry made into a medical record after a lawsuit is threatened or filed is suspect. Also, if the medical record is not updated promptly, there could be a lapse of memory about what actually occurred.
Completeness of Entries
The medical record may be the most important document in a malpractice suit because it documents the type and amount of patient care that was given. If the medical record is incomplete, the physician or other healthcare provider may be unable to defend allegations of malpractice, even if there was no negligence. For instance, in a 1985 Missouri case, a physician ordered that a patient be turned every two hours. The attending nurses, however, failed to note in the patient’s record when they turned her. The patient claimed that she had not been turned as ordered and that this caused her to develop serious bedsores, which led to the amputation of one leg. The nurses presented an expert witness who testified that in some instances nurses become so busy that they place the needs of the patient, such as turning, before the need to document. The court eventually dismissed this case. However, not all such cases are dismissed (Hurlock v. Park Lane Med. Ctr. Inc., 709 S.W.2d 872, Mo. Ct. App. 1985).
The medical record is a legal document and as such can be subpoenaed into court as evidence in a malpractice case.
In a California case, an appeals court ruled that the physician’s inability to provide the patient’s medical record created the inference of guilt. (Thor v. Boska, 113 Cal. Rptr. 296, Ct. App. 1974.) This is an example of a situation in which the physician may not have been at fault. However, the fact that he was unable to provide any documentation about his treatment of the patient meant that even at the appeals court level, he did not win his case.