In the world of healthcare, accurate medical charting is critical. Every note, entry, and update in a patient’s medical record plays a role in ensuring proper diagnosis, treatment, and continuity of care. But what happens when a healthcare provider makes a mistake in the chart? Can a charting error lead to a medical malpractice claim?
The short answer: Yes, it can.
What Is a Charting Error?
Charting errors can take many forms, including:
- Omitting important medical information (such as allergies or prior conditions),
- Recording the wrong medication or dosage,
- Documenting procedures that were never performed,
- Failing to update a patient’s status in real time,
- Using vague or incomplete notes, or
- Misidentifying the patient.
These kinds of mistakes may seem like clerical issues, but they can have serious, and sometimes fatal, consequences.
When Does a Charting Error Become Malpractice?
Not all charting errors qualify as malpractice. For a patient to have a valid malpractice claim, they typically must prove:
- A provider-patient relationship existed,
- The provider was negligent—meaning they failed to meet the standard of care expected of a reasonably competent healthcare professional, and
- The error caused harm—not just that the chart was incorrect, but that the mistake led directly to an injury or worsening of the patient’s condition
For example, if a nurse fails to chart a patient’s allergy to penicillin, and the patient is later given the drug and suffers an allergic reaction, that could form the basis of a malpractice claim.
Common Scenarios Where Charting Errors Lead to Legal Action
Below are a few common scenarios when charting errors have led to legitimate legal malpractice claims:
- Medication errors: A pharmacist dispenses the wrong drug because the chart was illegible or incorrect.
- Surgical errors: A wrong-site surgery occurs due to misdocumented notes or missing pre-op information.
- Delayed diagnosis: A doctor misses a critical symptom because it wasn’t noted in the record, delaying diagnosis and treatment.
The Role of Electronic Medical Records (EMRs)
While electronic systems were designed to reduce human error, they also introduce new risks.
Copy-and-paste shortcuts, autofill mistakes, and system glitches can all contribute to inaccurate records.
When providers rely on flawed EMR entries without cross-verifying, the patient may pay the price.
Proving a Charting Error in a Malpractice Case
Charting errors often become a focal point during litigation.
Medical records are one of the first things attorneys examine. Expert witnesses, such as other doctors or nurses, are frequently brought in to testify about the standard of care and whether the error was a deviation from that standard.
What Can Patients Do?
If you suspect that a medical error harmed you or a loved one, request a copy of your medical records.
Look for inconsistencies or gaps. Then, consult with a medical malpractice attorney who can help evaluate whether a charting error played a role in the harm you experienced.
Contact Otorowski & Golden, PLLC
Please know that our firm is here to help if you were injured due to a medical provider’s malpractice. Otorowski & Golden, PLLC provides free consultations to all our potential clients. The attorneys at our law firm also have over 120 years of combined experience representing injured parties in medical malpractice cases. They never back down to insurers and fight for their clients’ interests every step of the way. Do yourself a favor and contact them now for the quality legal representation you deserve.