Improper Record Keeping In Hospitals Is Serious And Can Even Be Deadly

Medical Records

Communication errors is the number one cause of medical malpractice and medical malpractice lawsuits. This communication is not just between the healthcare provider and the patient, but also between healthcare providers. It is the simple truth that communication is a basic and important part of providing the care and treatment necessary to treat for patients properly. When communications break down, medical errors occur.

This is why when record keeping also fails, patients get hurt and medical malpractice occurs. Record keeping is just a form of communication. Mistakes here are communication mistakes. However, these mistakes can not just be miscommunicated between a few providers, but all providers who rely on those medical records—both presently in the hospital and in the future care—can be mislead.

The worst types of record keeping mistakes occur in the OB/GYN and labor and delivery parts of hospitals. If nurses are misreading and miss-transcribing the fetal monitoring strips and other symptoms of a mother and fetus, it will completely throw off the entire hospital staff treating that mother and baby. That means the OB/GYN or family practitioner handling the delivery will not have accurate information and will not know the proper vitals of the patient. This can be deadly for the mother and the baby.

Another dangerous area of mistakes in record keeping is surgery. If the anesthesia team is improperly keeping track of the patient’s vitals, including heart rate, oxidation rate, blood pressure, and other vitals, it can mislead the whole surgical team. For instance, if the anesthesia team is not properly recording the blood loss, urine out, fluid in, and the blood pressure, there could be greater risk for the surgical team to damage vital areas like the spinal cord, organs, vessels, and other structures that strongly rely on the blood pressure and fluid being normal.

Record keeping for medications can also be fatal. A common rule is not documents, not done. But if a provider gives a strong painkiller and does not record it, another staff may come in and see the patient is due and give it again. This can easily result in an overdose and cause permanent damage and even be fatal.