Electronic Medical Records

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Electronic Medical Records

Jan 03, 2015

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An important aspect of President Obama’s health care reform was to stimulate doctors and hospitals to purchase and use software that generates medical records electronically. This would seem to be a good thing for patients. Indeed, in his state of the Union address in 2004, President George W. Bush stated “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care”.

The purpose of any medical record is to document the patient’s condition and symptoms, the doctor’s assessment and test results, and the doctor’s prescribed treatment. In a physician’s practice, the doctor can look back at old records and get a sense of the patient’s history and what diagnoses he made, and what treatments worked. In a hospital setting, the records are used as a means for the various health care professionals who have contact with the patient to communicate among themselves regarding the patient.

Medical mistakes often result from miscommunication among the health care professionals. Illegible records often contribute to the miscommunication and the mistakes. Electronic Medical records are intended to alleviate those mistakes.

MEDICAL MALPRACTICE CASES REQUIRE THOROUGH REVIEWS

Investigation of a potential medical malpractice case requires a thorough review of all the patient’s medical records, including those that are electronically stored and maintained. Traditionally, if there was any question about whether we received copies of all of a patient’s records, we could always ask to review the original set of records to compare to the copies. However, software programs for electronic records allow for the filtering of records prior to printing, and so it is often the case that a printed set of electronic medical records does not produce a complete set of those records. Just like any software program, the printed form of the records often does not correspond with what appears on the computer screen.

CLEVELAND ATTORNEYS PROTECTING PATIENT RIGHTS

We at the Spangenberg law firm have been involved on the cutting edge of insuring that a complete production of our client’s electronic medical records are produced. This includes, when necessary, filing motions with the court to force hospitals and doctors to allow us to review medical records on line at the defendant’s computer terminal. Often times, that is the only method which will guarantee that we have accessed a complete set of the records. Only then can we make sure that we have accomplished a complete and comprehensive review of what happened to the patient.

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