Vincent J. DeSalvo, Attorney at Law
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Electronic medical records can provide evidence of malpractice

What do you know about your doctor's record-keeping system?

The odds are good that your doctor no longer has paper files. Instead, he or she probably has a specialized computer system that stores electronic medical records, or EMRs. Your local hospital is likely the same way -- in fact, it may have moved into the realm of electronic records before your doctor's office.

All of those electronic records provide a wealth of information that can be useful in medical malpractice claims. In fact, they sometimes provide exactly the evidence that's necessary to prove that a hospital didn't provide timely care or didn't consider a diagnosis. The fact that many doctors and nurses also don't really understand just how the EMR systems work can often trip up someone who tries to cover up a mistake or lie.

When a medical professional logs into a patient's record, the electronic systems use a variety of methods to record information about each entry in the background, or metadata, of the system. This metadata can show exactly when each entry was made and who made it. It tracks changes as they were made. It can also show who simply looked at the chart -- and when.

If you're a victim of medical malpractice, all of that data can often demonstrate exactly what you allege. For example, if you're trying to show that a doctor at a hospital didn't take enough time to review your medical history or consider all the possibilities before deciding on a course of treatment, the electronic data might support that allegation by showing that the doctor never logged into your chart before stepping into the room and only spent three minutes on your whole visit.

Metadata can also catch medical providers in an attempt to deceive the court. For example, if a doctor tries to add an entry to show that a particular condition was considered and then dismissed for some reason, the metadata will show that the entry was added only after you had a negative outcome to treatment.

Many patients think that it's just "their word against the doctor's word" about what happened in the examining room. These days, that's not quite true, thanks to electronic record-keeping. If you suspect that you're the victim of medical malpractice, your records may prove it.

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