A doctor's medical records form the foundation for showing that there were departures from good and accepted medical practice leading to a patient's injuries.
In fact, we actually rely on the doctor's treating medical records in order to show to the jury that the doctor violated the basic standards of medical care.
While the defense often argues that inaccurate or incomplete medical records is not malpractice and likewise did not cause the patient's injuries, it is merely one piece of evidence the jury can use to evaluate the doctor's credibility.
This comes into play often with electronic medical records.
Many doctors tend to get lazy with electronic medical records.
They often cut and paste into templates which means that it has the same basic information over many different office visits.
It's highly unlikely that the patient's vital signs are exactly identical for 10 separate visits.
It's also unlikely that the patient's presenting complaints are the exact same for each and every visit over an entire year.
While poor record-keeping may not be evidence of malpractice, it clearly sets the stage for the jury to evaluate what type of person this doctor really is.
Is he sloppy? Is he lazy? Is he believable? Is he a really good doctor but just a terrible record keeper?
During pretrial questioning known as a deposition, I have an opportunity to ask the doctor you have sued questions about what he did and why he did it.
One line of attack involves getting the doctor to acknowledge that keeping accurate records are an important function of treating patients.
I then get him to explain why. I also ask whether it's important to keep thorough and detailed records.
That often draws an objection from the defense attorney and we begin to argue over what constitutes thorough and detailed records.
Regardless of which words the doctor uses, he must always acknowledge that it is critical to keep accurate records.
