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Gerry Oginski
NY Medical Malpractice & Personal Injury Trial Lawyer

Medical Malpractice in NY: What is the importance of having accurate, complete and thorough medical records?

 

A: During a deposition, also known as a question and answer session given under oath, I have an opportunity to ask the doctor whether he made notes at the time of your visit. It should be a no-brainer that the doctor agrees how important it is to keep accurate records; how important it is to keep complete records and how important it is to keep thorough records.

Once the doctor has admitted these basic truths, I can often point out areas within his records that are not complete, thorough or accurate. This line of questioning establishes a basic inconsistency. The same thing can and should be done at trial.

The natural extension of this line of questioning is that the doctor failed to record certain information. However, there are often excuses arising from missing information in a patient's chart.

The first is that the doctor did not ask a particular question. An alternative may be that the doctor asked and got an answer that was insignificant. The doctor may argue that because the answer was insignificant, he did not feel that warranted an entry in the record. Another alternative is that the doctor did ask, received an answer and simply forgot to record the information in the chart.

It is the attorney's job to distinguish which one of these alternatives occurred.

The only way to show this type of contradiction is by getting the doctor to first admit the significance of having accurate, complete and thorough medical records.