Is a Patient’s Chart More Important than a Patient’s Treatment?

By: Cohen, Placitella & Roth @ May 11, 2016

There is no doubt that medical documentation is a good thing. And to add to that, that accurate medical documentation is necessary. After all, many medical errors are made every year in the United States as a result of improper documentation and communication.

But can thorough documentation actually be a negative thing? According to Theresa Brown, who works in home hospice care and whose opinions are published in The New York Times, computer documentation in health care often gets in the way of a much more important thing: patient care.

When Documentation Is Prioritized

In today’s digital world, documentation is an incredibly important component in many industries, health care not excluded. To be sure, hospitals often enter information to record patients’ levels of pain, their “fall risk score,” their medical risk, and more. These programs are not optional for nurses and doctors, but instead mandated by hospital protocols, programs like Medicare Advantage, and other Medicare and Medicaid services. Brown also reports that despite the requirement of documentation, there are many errors made in the documentation process.

So What Is the Problem?

But what is the problem with documenting a patient’s pain or risk threshold? After all, wouldn’t thorough documentation be a good thing?

Brown explains that the problem with documentation is that it often gets in the way of actually treating a patient. For example, the Medicare Advantage requirement that mandates ‘upcoding’—or diagnosis and documentation of the most serious version of a patient’s health issues–does not require patients’ illnesses to be treated in any way. Brown further states that, “all the attention given to our paperwork is taking us further and further away from the difficult truth that meeting ill patients’ needs occurs in real time with real people, not in the paperwork about them.”

The Most Important Thing in Health Care

The most important thing in health care is arguably the efficacy of care provided, not how well that care—or rather, the patient’s condition—is documented. Without a shift in focus to patient safety, care, and accuracy in diagnosis, electronic records are futile.

If you are a victim of improper care in the medical system, you deserve to be compensated for your losses. Medical providers are obligated to exercise a high level of care in diagnosis and treatment; if that level of care is not met and harm results, the health care provider or hospital in which he or she is employed may be held liable for damages.

Speak with a Medical Malpractice Attorney Today

Failure to keep thorough documentation (leading to patient harm) and failure to appropriately treat a patient (when documentation suggests that treatment should be administered) are both acts of negligence. If you believe that you are a victim of negligence from a medical professional, do not wait any longer to call an experienced New Jersey and Pennsylvania medical malpractice attorney.

To schedule a free case consultation with a lawyer who will keep your best interests in mind, call the law firm of Cohen, Placitella & Roth, P.C. today. You can call our offices directly, or use our online form to request your first meeting.