Top Four Attorney Concerns About Medical Records Part 2: Lack of Uniformity of Charting Systems

By Tracy L. Liberatore Esq, PA

This is a continuation from my prior article regarding attorney concerns and looks at the second item on the poll run by Pat Iyer; lack of uniformity of charting systems.

You Are Not Alone

Attorneys are not alone with this frustration as many medical providers have the same frustration; especially now with the implementation of the electronic medical record. It makes it difficult for physicians and mid-level providers to move fluidly between facilities. Many doctors have privileges and more than one hospital, and this poses a problem for training and learning how to navigate the charting system for each hospital where they see patients.

The other problem this poses for the physician is not being able to find things in the record. Flipping through volumes of pages posed a problem in that things could get lost in the chart. The electronic record issue stems from not knowing where to go to find something. The overall dysfunction that ensued after the implementation of the medical record will be examined more in depth in a future post. For now, the focus is on the lack of uniformity from one facility to the next.

Sense Can Be Made

While it can be said there is certain uniformity- namely the SOAP note format that all physicians use to write their notes – the variations on how these notes are completed is great. Some facilities use preprinted forms where the physician can simply check off a box that they examined an area of the body, or asked a certain question. Others yet dictate or handwrite the entire note. There are now electronic record systems that utilize a combination of these methods where there is an area to free type and a check box system all in one program. These are just the doctor’s portion of the record. There are also nursing notes, flow sheets, notes left by ancillary staff etc.

The task of sorting through all this documentation can be daunting when one does not know what they are looking at, what they are looking for, or where to find it.

While there is no uniformity as to where things go in a chart, there are some universal standards known among medical professionals. There are certain things we know to look for, seek out, and recognize in a medical chart so we can care for our patients clinically.

This knowledge, training, and experience can be useful to the attorney trying to do the same for a client.

Unfortunately, they do not teach these things in law school, or even medical school for that matter. It only comes after years of clinical practice taking care of patients.

Help Is Available

This is where the medical legal consultant comes in! Fortunately for the attorney, there are those of us who have been accused of going to the dark side. We chose to change professions and make a difference in the lives of people who are injured by malpractice. We chose to help the attorney rather than the physician. We do not consider it the dark side, rather an opportunity to help the unfortunate recipient of a medical misfortune. I see it as finding my way into the light!

If you find yourself faced with medical records that do not make sense, help is only a phone call away! Med Legal Pro is your solution!

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