Why Charting Errors Create Serious Treatment Risks

In a medical setting, providers need to ensure that your medical charts are up to date. Your chart should contain current symptoms, test results, and other pertinent information. Failure to update the chart promptly can lead to serious treatment risks. Proper charting can mean the difference between life and death in some cases. With death as a possibility, charting errors are not something you should take lightly. When a charting mistake that leads to injury happens to you, reach out to an experienced law firm like Pittman, Roberts & Welsh, PLLC for help.

Charting Errors and Medical Negligence

Charting errors, due to medical negligence, lead to inaccurate medical records. Failure to add information to the chart can result in extensive problems. Similarly, adding in information that doesn’t belong can create serious issues. In the most severe instances, charting issues can lead to the loss of life. Charting errors create numerous problems. Some of these issues include medication errors, surgical mistakes, and more.

Medication Errors

When the medical professionals don’t keep your chart current, your medication list may not be accurate. This can result in a plethora of health issues at your next doctor visit or hospital stay. A doctor may prescribe medication for anxiety, but the one in your chart might be for a heart condition. If you don’t have a heart condition, this is a major discrepancy. If you were to go to the hospital in an emergency, they may start administering the heart medication that you don’t actually need. This can create severe adverse reactions. Not only that, but if they run tests, it can skew the data. The medical team may start looking for an issue that you don’t actually have. It only occurred due to a charting error, which led to providers giving the wrong medication.

Other problems can arise from incorrectly charting medications. You may need a specific medication once a day. If someone writes in your chart that you need the medication every four hours, that can cause serious issues to occur. The same is true if providers write the incorrect dosage in your chart. On top of dosing and frequency, omitting allergy information is another charting problem that has major consequences. In an emergency, a doctor may administer medication you are allergic to. This can happen when information regarding allergens isn’t in your chart. This can cause a serious allergic reaction that proper charting could have prevented. Many of these charting errors revolving around medications have the possibility of resulting in an overdose or death.

Mistakes Regarding Surgeries and Procedures

When medical charting is not fully complete or current, it can lead to issues with surgeries and various procedures. When your chart has an error, the medical team may take you back for the wrong surgery. This can happen where there is an issue with your electronic medical records. Due to the records they are looking at, there is a possibility they might misidentify you. Faulty scheduling is another charting error that can lead to them taking you back for the wrong procedure.

In other cases, even if the type of surgery is correct, they may do it at the wrong site on your body. This means that the surgery was for the arm on the left, but it was actually done on the right. This could also mean that they completed the surgery on the wrong organ. When this happens, there are two main charting errors to blame. One is incorrect mapping. The other is wrong pre-op documentation.

Another large aspect of charting during surgeries has to do with instrument counts. Medical staff must keep an accurate count of tools used in the operating room. This includes things like sharps and sponges. The operating room staff must count and record these numbers before the procedure begins. They will have to complete an accurate count again before both cavity and skin closure. The number must match at all times. If it doesn’t, staff must notify the surgeon as soon as possible. After that, they will begin a search to find the missing instruments. Providers must write any additional medical search methods they use in their charts. This could include noting that they used an X-ray to find the materials. They also must reveal if they found the missing tool or not.

An inaccurate count that gets documented as a matching number in your chart is serious. This means that a search was likely never done. You may have a retained surgical object within your body. This is a major safety concern. A loose scalpel blade or needle within your body can cause an immense amount of damage. Proper charting of the counts prevents severe issues such as this from happening.

How to Handle Charting Errors

There are a few ways you can handle medical charting errors. If you suspect an error within your chart, you should start by requesting all of your records. The best way to do this is by using patient portals. Once you receive your chart, you need to identify the parts that aren’t accurate. To correct these discrepancies, request in wiring the things you want them to update. If harmful treatment occurs due to charting errors, report it to the patient safety department within the facility. The next steps are to formally file a complaint and add a statement of disagreement. These two steps are beneficial if the provider refuses to update your chart. If medical charting errors resulted in serious consequences to your health, there is one additional step you should take. Reach out to a medical malpractice lawyer to help you receive compensation for your pain and suffering.