Medical malpractice is a legal cause of action initiated when a medical or healthcare professional falls below the acceptable standard of care, causing injury or harm to a patient. Medical malpractice law imposes liability when a healthcare professional fails to exercise a fair, reasonable, and competent degree of skill when providing medical care to a patient. In most jurisdictions, the specific professionals a medical malpractice action may target will vary. However, some common types of professionals are routinely subject to these suits and may be potentially liable under medical malpractice laws in the jurisdictions where they practice. These include, but are not limited to, physicians, surgeons, psychiatrists, dentists, nurses, midwives, nurse practitioners, physician assistants, and other health professionals allied with these professionals (i.e., psychologists, pharmacists, social workers, occupational therapists, etc.). In many jurisdictions, a medical malpractice lawsuit is initiated officially by filing and serving a summons and complaint. The parties are then subjected to discovery, a process in which documents such as medical records are exchanged, and depositions are taken by the parties involved in the suit. Medical records and similar documents become crucial in proving liability in these cases. The pursuit, processing, accuracy, and review of those records are essential to whether the case will succeed.
A plaintiff must establish four key legal elements to succeed in a medical malpractice claim, all of which must be established and proven.
- Duty of Care
- A healthcare provider must exercise reasonable care under the circumstances. Specialists have a higher standard of care that is acceptable to their advanced professional focus.
- Breach of Duty of Care
- A breach of duty of care occurs when a healthcare provider fails to act within the level of skill, knowledge, and care ordinarily expected of a reasonably competent provider under similar circumstances.
- Causation
- The failure or breach of that duty of care must have caused harm or injury to the plaintiff.
- Damages
- The breach of duty of care, which caused the harm or injury, must have resulted in damages to the plaintiff (i.e., physical harm, economic harm, etc.).
Evidence of Standard of Care
Medical record retrieval is important in confirming that all relevant information is obtained and accessible for analysis. This will help determine whether a medical provider breached, violated, or fell below the standard of care acceptable in the profession. This becomes the essence of the medical malpractice claim(s). To prove this, there must be some evidence that the professional failed to meet the standard of care. Medical records serve as the primary source of information to establish this. Records contain the patient’s medical history, treatment plans, prescribed medications, test results, and physician notes. These records help experts determine if the care provided was consistent with the accepted medical practices and procedures.
Breach of Standard of Care
When a medical practitioner fails to act with the level of skill, knowledge, and care that is ordinarily expected of a reasonably competent practitioner under similar circumstances, this will normally be argued as a breach of that standard of care. Some types of breaches include: 1) misdiagnosis or delayed diagnosis, 2) surgical errors, 3) medication errors, 4) failure to obtain patient informed consent, 5) improper treatment, 6) failure to monitor, and the like. Proving a breach of care typically requires clear, sufficient, and accurate medical records and corresponding documentation to demonstrate deviations from accepted practices. Retrieving, reviewing, analyzing, and presenting medical records as the primary source of information is essential in documenting and proving that negligence occurred. This information can contain a patient’s medical history, treatment plans, prescribed medications, test results, lab results, and physician notes. These records help determine whether the care provided was consistent with the accepted practices.
Supporting the Claim (Plaintiff)
Plaintiffs are the party bringing the malpractice claim(s) and allege the injury or harm. The patient’s medical records are vital to establishing the extent of the harm caused by the alleged medical negligence. These records can include information that can lead to errors in diagnosis, omissions to act by the medical practitioner, treatment plan, post-operative care, medications prescribed, and prognosis timelines. These items collectively are critical in proving the claim.
Defending the Claim (Defendant)
Defendants are the medical practitioners subject to the alleged malpractice or negligence claims. Medical records are vital for the defense and can show that the standard of care was followed and that the alleged injury or harm was not a result of negligence. Well-documented records can help counter allegations and demonstrate that proper care was provided.
Establishing Causation
Establishing causation is a key challenge in medical malpractice claims. The key legal concept revolves around whether the injury or harm was foreseeable. The concept of causation limits a defendant’s liability for negligence to consequences reasonably related to the negligent conduct. For plaintiffs, medical records can link the alleged negligent act (i.e., missed diagnosis or surgical error) to the harm the patient experienced. For example, a missed diagnosis led to a delayed diagnosis, causing additional unnecessary harm or an incorrect procedure, which led to a surgical error that caused the harm. Causation can be a difficult element to prove in medical malpractice cases. The proper medical records can make this process easier and are often essential to bridging the gap between the alleged injury and the defendant’s liability.
Damages
Damages include monetary compensation awarded by a court to an individual whose negligence or malpractice of a healthcare practitioner has injured them. The purpose of damages is to restore the injured party to a position the party was in before they were harmed. Medical records are essential in the determination of awarding damages. An injury plaintiff, for example, who proves that a defendant’s actions or inactions caused the injury but fails to submit medical records to show the extent of the injury may only be awarded nominal damages or receive no compensation at all.
Speed and Accuracy of Record Retrieval
Time is often critical in medical malpractice cases. Delays in obtaining medical records can hinder a case or cause unnecessary issues, especially when evidence is needed to establish or refute a claim. Using a reliable record retrieval company ensures the process is efficient and minimizes delays. Furthermore, the records retrieved must be accurate and complete. Missing or incorrect records can create significant challenges in the case, leading to mistakes in establishing facts, delays in the legal process, or failure to develop any of the four key elements of proving negligence in a medical malpractice action.
Summary
Record retrieval is indispensable for gathering evidence to support or refute negligence claims in medical malpractice cases. There can be no appropriate case adjudication without properly documented medical records. Whether establishing standard of care was met or deviations from protocol, accurate and timely access to medical records plays an important part in the case and ultimately in providing justice. Employing a reliable record retrieval provider ensures that the medical records obtained are accurate and complete, which ultimately helps strengthen the case.
