When a patient is harmed due to suspected medical negligence, one of the most critical pieces of evidence in a medical malpractice case is the doctor’s chart. Often referred to as the patient’s medical record, the doctor’s chart provides a written account of the patient’s condition, treatment, and interactions with healthcare providers. In litigation, this document can help uncover what went wrong, when it happened, and who may be responsible.
What Is a Doctor’s Chart?
A doctor’s chart is a comprehensive medical record that includes:
- Patient history and physical examination notes,
- Progress notes documenting the patient’s condition over time,
- Orders for tests, medication, or procedures,
- Lab results and imaging reports,
- Nurse and staff notes,
- Informed consent forms, and
- Discharge summaries and follow-up instructions.
This documentation serves both a clinical and legal purpose. Clinically, it ensures continuity of care. Legally, it becomes a timeline of events that can support, or undermine, a malpractice claim.
Why the Doctor’s Chart Matters in a Malpractice Case
In a medical malpractice case, the plaintiff must generally prove:
- The existence of a provider-patient relationship,
- A breach of the accepted standard of care,
- That the breach caused injury, and
- The damages that resulted.
The doctor’s chart can support or challenge each of these elements.
Note that, as to the standard of care, medical records show what care was provided and when. By comparing this documentation with expert testimony about what should have been done under similar circumstances, attorneys can evaluate whether the standard of care was breached.
Further, as to causation, the chart helps establish a timeline of care, which is vital in demonstrating causation. For example, the chart can show that a doctor did not respond promptly to warning signs. Or, it can show that delays in diagnosis or treatment contributed to an injury.
Potential Challenges with Medical Records
While the doctor’s chart is a powerful tool, it is not always perfect For example, it may contain:
In these situations, expert review and testimony are often necessary to interpret the records and fill in the gaps.
- Incomplete or vague entries that can obscure the facts, and
- Illegible handwriting or poor electronic recordkeeping that can complicate interpretation.
Best Practices for Patients and Attorneys
For patients suspecting malpractice, it is important to request a copy of your medical records as soon as possible. Under HIPAA, patients have the right to access their records, and delays in obtaining them can make it harder to preserve key evidence.
Attorneys should work with medical experts to review the chart thoroughly. Sometimes what is not in the chart, such as a missing test result or unrecorded symptom, can be just as telling as what is.
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.