Hospital Medical Charts – Medical Neg Claims Article
August 12, 2015
This article addresses medical negligence claims based upon patient care in hospitals. More specifically it describes the patient’s medical record and how the charting provides essential information about the claims and defenses to those claims. Whether one represents plaintiffs or defendants, the hospital chart is the single most important source of information about the viability or defensibility of a medical negligence claim.
The elements of a claim for negligence of a healthcare provider are described in ARS §12-563:
Necessary elements of proof:
Both of the following shall be necessary elements of proof that injury resulted from the failure of a health care provider to follow the accepted standard of care:
- The health care provider failed to exercise that degree of care, skill and learning expected of a reasonable, prudent health care provider in the profession or class to which he belongs within the state acting in the same or similar
- Such failure was a proximate cause of the injury.
Medical negligence claims for care provided to a patient in a hospital pose unique challenges for plaintiffs, defendants, and their counsel. A hospital chart is a comprehensive record of the care provided, the reasons for the care, and record of the patient’s response to the care. Patients in hospitals are cared for by many different nurses, physicians and others. Every important observation of the patient is recorded in the chart. Physician orders, requests for specialty consultations, the consultant reports, blood work, lab work, imaging studies, and results of all other diagnostic and therapeutic interventions are recorded in the chart. By the same token, as a general rule, if something isn’t in the chart, as a rule of thumb, it did not happen.
Understanding the chart requires an understanding of how it is organized.
Hospital charts are organized both chronologically and in sections based upon the type of information (progress notes, physician orders, nursing progress notes, medication administration records, vital sign flow charts, etc.); and based upon the type of health care provider generating and recording the information, (nurse, physician); and the type of information (laboratory, bloodwork, metabolic studies, x rays, etc.).
The information is generated by different categories of caregivers within a shift, and by different individuals in the respective caregiver categories from shift to shift.
The notes from a given shift are used to communicate information about the patient’s condition from earlier points in time to caregivers who become involved afterward .
There are entries from doctors, nurses, specialty consultants and potentially a host of others who care for the patient in the hospital. Many are handwritten. In fact, it is the handwritten notes that often provide the most timely and important information about a patient’s condition. The typed consults of specialists, for example, are first handwritten into the patient’s chart at the time the specialist sees the patient. The dictated and transcribed consultation notes aren’t put into the chart until they are complete, which is often days later, and can be after the patient is discharged.
The chart allows caregivers to identify the people who have cared for the patient throughout the hospitalization. It serves the same purpose for lawyers trying to determine the caregivers after the fact.
The entries in the chart provide a chronological record of the care the patient received, the diagnoses, the reasons for the care, observations of the patient’s response to care received, and the patient’s outcome.
The time of entries in the records permits conclusions about the patient’s condition at other times although the condition at those other times is not recorded.
Normal vital signs charted 2 minutes before the patient is found not breathing and unresponsive, suggests the patient could not have been unresponsive for more than two minutes.
Inconsistent chart entries by different people at approximately the same time can be harmonized or explained by other entries in the chart.
For example, a physician describes a patient as “doing better”, “appears excited to go home”, “will likely discharge home later this afternoon”, at approximately the same time a nurse charts, “patient lethargic”, “slow speech and flat affect”, “appears depressed”. If the vital signs recorded at the time are normal, it is less likely the nurse’s observations are accurate. If the patient’s respirations are 10 or lower, it is less likely the patient looks as described by the doctor.
Hospitals have written policies, procedures, nursing protocols and standing orders for what information is recorded, how it is recorded, and what information is required before a given therapy or diagnostic study can be performed.
The importance of the hospital record is addressed in employee orientation
programs. It is the subject of nursing job performance evaluations and adequate hospital standards regarding information management, covered by the JCAHO hospital accreditation standards, which must be complied with by a hospital to obtain a license to operate in Arizona.
As a practical matter, the presence or absence of an entry in the patient’s hospital chart often is an essential factor in assessing the viability of a medical negligence claim.
As an example, patients are discharged from the hospital with a set of written instructions. Typically, the instructions are discussed with a nurse before the patient leaves the hospital. If the nurse testifies she told the patient to return if not better in 2 days, but that instruction is not in the written document, which might support the plaintiffs claim that he wasn’t told to do so.
The importance of the hospital chart cannot be overstated. This article barely touches the surface of the topic. If you have questions about a hospital chart in one of your cases, you can contact the author at, firstname.lastname@example.org.