In legal actions involving medical malpractice or negligence, medical records become the most important evidence introduced at trial. Medical records provide insight into the patient’s medical history, current complaints, and treatment plans. Not only does it provide evidence for what caused the patient’s injuries, but it also helps tell the patient’s story. If a medical professional does not maintain accurate and detailed medical records, a legal nurse consultant will be able to point out the action, or omission of an action, which caused the patient to suffer damages.
A medical professional should always strive to provide the most accuracy in their medical records because the records form a permanent account of a patient’s treatment. For this reason and many more, medical professionals are encouraged to properly document every detail and to carry on these practices throughout their career. To ensure accurate and detailed medical records, medical professionals should follow these five practices:

1. PREPARE REPORTS SHORTLY AFTER THE DATE OF SERVICE
Procrastination is a common struggle people suffer through, and medical professionals are not an exception. However, procrastination can lead to inaccurate reports. Medical professionals usually see dozens, if not more, patients each day. Due to the sheer volume of patient visits, it is impossible to remember all details of each appointment. To ensure accuracy of the medical records, create a system in which you can take notes about key factors occurring during the appointment which provides insight into the patient’s health. If the medical doctor is unable to take the notes, then it is important to bring in a nurse, or other medical assistant who can assist with taking the notes to document the visit.
Unfortunately, there are certain situations where notes cannot be taken during a visit. These situations generally arise in the emergency room department or operating room where all hands are required during the procedures. In order to ensure the medical reports are as accurate as possible, it is best practice to collaborate with the other medical professionals involved during these situations to ensure everyone agrees with the procedures that took place.

2. INCORPORATE COPIES OF TEST RESULTS
Often medical professionals are unable to make a proper diagnosis without referring the patient out for diagnostic testing. These tests may include MRIs, blood work/urine samples, or neurological testing, and will provide the medical professional with more insight into the patient’s complaints. The doctor will review the results of the tests and then make a more informed decision as to what the underlying illness or problem is causing the patient’s ailment. Since these test results are important and show the review performed by the medical professional, it is important to incorporate these test results into the medical records. Otherwise, a legal nurse consultant may find errors in the treatment provided if the medical professional did not consult any diagnostic testing to confirm the malady.

3. GO ELECTRONIC
Incorporating technology is incredibly beneficial in every professional arena including medical practice. Electronic Health Records (also referred to as “EHR”) streamline a medical professional’s ability to create the health records during the appointment. Most doctors’ offices are now equipped with computers in the examining rooms and throughout the office to ensure the medical professionals can access and notate the record whenever it is needed.
Another benefit of going electronic is it frees up space within the office instead of relying on cabinets to hold the patients’ files. It also provides easier access to the patient when he or she wants to request their medical records. Records that are electronically stored also provide a more efficient way for an attorney to request and receive the medical records to provide to the legal nurse consultant.

4. DOCUMENT CAUSE AND EFFECT
When documenting the medical records, medical professionals should always follow the “cause and effect” analysis. The medical professional should list out the patients’ complaints and then provided causes for each complaint. This provides a thorough analysis for the legal nurse consultant to understand the medical professional’s reasoning behind treatment recommendation and how they made the diagnosis.
If medical professionals do not follow a “cause and effect” analysis, it can only diminish the standard of care provided to the patient. By not providing details about what exactly is causing the patient’s health complaint, then the medical professional does not demonstrate how they concluded in their diagnosis and treatment recommendations. Since many people will have different medial histories, it is important to document how a certain factor in the medical history could cause the complaint and a particular diagnosis. The medical professional should also explain why a specific treatment which would typically be recommended is not recommended for a particular patient because it could lead to an adverse reaction displayed in the medical history.

5. INCLUDE FOLLOW UP INSTRUCTIONS AND TREATMENT RECOMMENDATION
In order for a legal nurse consultant to have a full understanding of what went wrong during a patient’s medical treatment, medical professionals need to include follow up instructions and recommendations. These recommendations could include prescription medication, further diagnostic testing, or placing dietary or physical activity restrictions. If these are omitted from the records, then it is possible a medical professional can be found liable for not providing the recommended treatment or advising the patient to follow up with another specialist leading the patient to sustain significant injury and damages.

Legal nurse consultants provide a cost-effective and efficient tool to utilize in your medical case. SPLNC & Associates has a team of legal nurses, with a vast knowledge of understanding medical issues and trends. The legal nurse consultants at SPLNC & Associates work in collaboration with the lawyer to get the cases across the finish line. As a legal nurse we take pride in our work product.
If you are interested in hiring one of our legal nursing consultants to assist with your medical case, please contact us at 517-256-5011.