Medical Chart Review Can Be Key Evidence in Medical Malpractice Cases

A patient’s medical chart is one of the strongest pieces of evidence in a medical malpractice case. It provides a written record of a patient’s symptoms, test results, diagnoses, orders, and treatments. It reveals what their medical providers and care team knew, when they knew it, and what they chose to do in response. A patient’s chart can also reveal red flags, omissions, inconsistencies, and documentation failures that may indicate medical negligence.

Under Michigan law, a plaintiff must file an affidavit of merit from a qualified expert witness with a medical malpractice complaint. This expert must conduct a thorough review of the plaintiff’s medical chart. They rely on the documentation in the chart to support their professional opinion that the plaintiff’s medical provider failed to meet the applicable standard of care and caused harm. Without this testimony, a plaintiff can’t proceed with their case.

How Can a Medical Chart Prove Negligence?

Medical records contain thousands of data points: vital signs, medication records, nursing notes, physician orders, diagnostic reports, timestamps, and more. When something goes wrong, there’s usually evidence lurking in the chart. A thorough and comprehensive review of a patient’s records can reveal mistakes, omissions, or attempts to conceal negligence.

Many types of chart irregularities can serve as “red flags” for identifying negligence in a malpractice claim. Some common issues include:

• Missing documentation or gaps in the record. A patient’s records should include regular notes from physician examinations and nursing assessments from each shift. It should also include imaging records, lab results, and results of any other diagnostic testing. Incomplete or missing records can suggest several negligent options, including sustained periods of patient neglect, monitoring failures, or missed medication. Piecemeal records can also reveal after-the-fact attempts to conceal evidence of wrongdoing.

• Non-contemporaneous documentation. Providers should create chart records when they provide care (or as soon as possible thereafter). Chart documentation that seems to have been created or altered significantly after the fact should raise concerns. Timestamps that appear illogical or out of sequence may indicate someone made, changed, or supplemented chart notes after an adverse event or to conceal negligence.

• Inconsistencies between providers. When notes from nurses, physicians, and specialists contradict one another, it can indicate communication breakdowns or poor-quality care. For example, if a nurse’s notes document worsening symptoms, while the physician’s notes from around the same time say the patient is stable, it may suggest a care issue or an outright falsehood.

• Inconsistencies between tests and notes. Chart notes that seem inconsistent with test results, imaging, or other supporting documentation can be another indication of mistakes, negligence, or dishonesty. For example, a note claiming to reflect an unremarkable bedside exam performed during the doctor’s rounds can’t be accurate if the patient was undergoing surgery or an imaging test at that time.

• EMR system issues and errors. Electronic medical record (EMR) systems can create confusion in a patient’s medical records. Auto-populate, autocorrect, and voice recognition features can insert incorrect words, phrases, or medication names. Providers must ensure their chart entries are correct and complete, including identifying and correcting these types of mistakes.

In every Michigan medical malpractice lawsuit, a qualified medical expert must thoroughly review the plaintiff’s medical chart before forming an opinion that the providers breached the standard of care. In addition to supporting the initial affidavit of merit, a plaintiff’s medical experts often use the chart to provide testimony under oath at a trial or deposition. This testimony may include:

• Describing the type of care provided to the plaintiff.
• Discussing whether that care met accepted medical standards.
• Identifying omissions or delays that caused harm.
• Identifying discrepancies or omissions that challenge a provider’s explanation.
  
  

Michigan courts rely heavily on expert testimony to help the judge and jury understand complex medical issues. As a result, an expert’s careful review of the patient’s medical chart can significantly affect the outcome of a case.

Chart Review Supports Evidence of Damages

In addition to providing evidence of a provider’s negligence, a comprehensive chart review helps establish the full scope and basis of the plaintiff’s damages. Expert testimony based on the medical records helps establish the severity of the harm, the long-term effects on the patient’s physical and emotional health, and the full scope of the financial damages related to a provider’s negligence.

Accurately understanding these details is essential to negotiating a fair settlement or persuading a jury to award the plaintiff full compensation for their losses. An expert’s review and testimony about the patient’s medical chart is a crucial part of a successful claim. Every line, timestamp, and notation helps the judge and jury understand what happened, who is responsible, and how much compensation the plaintiff deserves. The medical malpractice attorneys at Sommers Schwartz, P.C., have decades of experience advocating for the rights of Michigan families and securing compensation for victims of medical malpractice. Contact us today to schedule a free, confidential, no-obligation consultation.