Episode 079: Missteps in Medical Records

Speaker 1: You are listening to Your Practice Made Perfect, support, protection, and advice for practicing medical professionals, brought to you by SVMIC.

J. Baugh: Hello everyone, and welcome to this week's episode of Your Practice Made Perfect. My name is J.Baugh, and I'll be your host for this episode. Today we're going to look at another one of our closed claim files. I feel like we can always learn something in looking at these files, maybe things that were done well, and maybe some things that could have been done differently. Today we have Katy Smith back with us. Katy, welcome.

Katy: Hey, J, thanks so much. I'm glad to be here.

J. Baugh: Well, it's good to have you. Katy and I are both senior claims attorneys here at SVMIC. Katy has been here 13 years. I've been here 18. And so she and I have seen a lot of cases while we've been here. And so today we're going to look at three cases that are directly related to the simple and, well, obvious topic of knowing your medical record. 

It shouldn't even be necessary to discuss this, because it's presumed that everyone knows what's in their medical records. But that presumption is rebutted each and every day by reality. The reality of a steady stream of patients, many with complicated and extensive histories, or of procedures taking longer than expected, leaving little time for a complete review of the medical record. Then there's peripheral business and insurance issues that can slow the practice of medicine to a crawl. And then we have that issue that is difficult...

Katy: A love-hate.

J. Baugh: That's right. We all thought electronic medical records were going to make things easier, and unfortunately, that isn't always the case. Sometimes EMRs make things more difficult. And so we know that physicians have all of these things that they have to deal with on day-to-day basis.

Katy: That's the reality of practicing medicine. We know that it's not just taking care of your patient and reviewing your medical record. There's so much facing our physicians these days. But the medical record is really crucial. If there's a problem with your record, you can have a catastrophic result. Unfortunately, that's what we're dealing with in these three cases.

J. Baugh: That's right. We're going to be dealing with three cases that talk about knowing your medical record. And so let's begin with the case involving an expectant 34-year-old mother who underwent routine screening for Group B strep as ordered by the doctor. The OB physician assumed that the test result was transmitted to the hospital. The result was positive. It was scanned into the patient's EHR which was maintained by the doctor since he was the one that ordered the test. Unfortunately, the result of the test went unread.

Katy: That's the number one stumbling block, I think. I'm not sure how a test result, any test result, but certainly a Group B test result, goes into the record without it being reviewed by the physician. But, nevertheless, it did. On the day of delivery, the patient had a vaginal delivery. It was performed as though the result was negative because neither the hospital nor the doctor thought otherwise. 

The doctor assumed the result was negative because the hospital scheduled the patient as a routine vaginal delivery. Of course, the physician's chart was in the hospital chart. It had previously been sent over to the hospital. So the positive test result was there in the hospital chart, readily available for the physician and the hospital staff to review. It was not reviewed, unfortunately. Mom had an uneventful delivery of a male baby, and both Mom and baby were discharged home.

J. Baugh: However, the mom returned the day after discharge when the baby began suffering seizures. It was then that the doctor saw Mom's positive Group B strep test, and the male baby was diagnosed with sepsis and meningitis. After a prolonged hospital course, he was discharged to return home. And so a lawsuit was filed after that. So Katy, what was the outcome of that lawsuit?

Katy: A lawsuit was filed against both the obstetrician and the hospital. Litigation was prolonged, as is not uncommon with litigation, but also in this case here, we have a very young patient. Time had to pass so that the extent of the injury to the child could be determined. Ultimately, unfortunately, the child was found to have some fairly severe neurological deficits from the untreated Group B strep. Ultimately, the case was settled by all the defendants before going to trial.

J. Baugh: Now you know, Katy, this really is a sad case for a few different reasons. One, obviously, is the outcome that the patient had. But it's also a sad case because it could have been avoided if the medical record had just been consulted.

Katy: Yes.

J. Baugh: I mean we're not talking about a medical record that got lost or got misfiled and they didn't know where it was. I mean this was a medical record that was in the patient's chart.

Katy: It was there, available, ready.

J. Baugh: Yeah. And somehow it got in the chart without anyone reading it, which is sort of a reminder to our listeners out there to review your processes and see if that's even possible for that to happen in an office setting. And if there's some way that that is possible, then you need to review your processes to ensure that that doesn't happen in your office.

Katy: Yes. I agree.

J. Baugh: So the next case involves a 29-year-old male patient who presented to the gastroenterologist with a laundry list of abdominal issues, including diverticulosis and irritable bowel syndrome. The patient was new to the area and was establishing care. And so when he came to the doctor's office, he filled out a new patient questionnaire, since this was his first visit to this doctor. And he noted on that questionnaire that he had Ehlers-Danlos syndrome, which is a connective tissue disorder. He had some mild complaints, and they were treated conservatively.

Katy: So the patient returns to our gastroenterologist less than five months later, though this time he has a more severe presentation. He's got severe abdominal problems, including bloody diarrhea. Because of the presentation as well as his history, the doctor scheduled the patient for an immediate EGD and colonoscopy. On the pre-procedure form for the endoscopy center, the patient did not note that he had Ehlers-Danlos syndrome. The procedures went well. The patient went home.

J. Baugh: But later that evening, the patient called the office saying that he was vomiting and had some abdominal pain. And so the doctor prescribed phenergan and set up an appointment for the next day. However, before the patient could be seen, he went into cardiac arrest and suffered brain damage. It was later determined that the patient's duodenum had been perforated during the procedure, and so as you might expect, a lawsuit followed.

Katy: So the lawsuit alleged that the doctor should have been more aggressive in treating the patient's post-procedure complaints in light of the connective tissue disorder, the Ehlers-Danlos syndrome. The defense for the gastroenterologist was that the patient didn't write on the endoscopy center pre-procedure form that he had Ehlers-Danlos syndrome, although of course the weakness with that argument is that that information was in the gastroenterologist's own chart. So the case went to trial, and a jury ultimately agreed with the plaintiff's argument, and a significant verdict was rendered against the doctor.

J. Baugh: Yeah, it's really difficult for the doctor to blame the patient for filling out one form where he did not say that he had Ehlers-Danlos syndrome, that is the pre-procedure form, when he had actually marked that on another form, his new patient form. He said from the very beginning of establishing a relationship with this physician, "I have Ehlers-Danlos syndrome." And so because it was in the chart, it's difficult to blame the patient because he didn't completely fill out the pre-procedure form.

And so again, we return to a situation that could have potentially had a different outcome if the doctor had just referred to his own medical record. Again, not a record that was lost, not a record that was misfiled in another patient's chart. But it was information that was in this patient's chart that was not used by the physician.

Katy: That's the consistent thing with these two cases, and I think it continues in our third. The bit of information that's so crucial to treating the patient properly is there for the doctor.  And it just is not utilized. It's not recognized.

J. Baugh: That's right. So this last case involves a young male patient who was referred by his pediatrician to a local ENT because of continuing issues with upper respiratory tract infections. At the initial visit, the parents noted that the son also suffered from frequent restless and noisy breathing while sleeping. The ENT sent the child for a study to determine if he had sleep apnea, which would dictate the best place for him to have a surgery. So it was very important in this particular setting to determine whether or not the patient had sleep apnea. And so in the meantime, surgery to remove his tonsils and adenoids was scheduled at the ambulatory surgery center.

Katy: So the plan was, if the sleep study confirmed that the child had sleep apnea, the surgery was going to occur at a nearby hospital because the patient is a higher risk. The study did confirm this. The child did have sleep apnea. However, as with our first situation, our group-B strep case, the result was placed unread in the doctor's chart.

The doctor was unaware of the sleep apnea results. The surgery took place at the ambulatory surgery center, not the hospital. After the ENT finished what appeared to be a routine surgery, he left the patient with the anesthesia team to awaken the child and discharge him home.

J. Baugh: Yeah, but the problem was the child didn't awaken very easily, again because of the sleep apnea that he had. So the anesthesia team administered oxygen via an Ambu bag and a mask, and eventually they administered Narcan. So everyone involved was still unaware of the sleep study finding of apnea. No thought was given to transferring the child to the hospital. And finally, the patient was stable enough to send him home, and so they did that. But later that night, the parents found their son with a bluish color and in respiratory distress. The child was rushed to the ED and resuscitated. He was admitted for an extended stay, but unfortunately, he passed away.

Katy: So the family retained an attorney, and it's unclear from the information I have whether or not suit was actually filed. But the attorney argued that the procedure should have never taken place in the ambulatory surgery center due to the patient's sleep apnea. Of course, the physician had a difficult time refuting that, because that was, in fact, his plan. So ultimately, an out-of-court settlement was reached.

J. Baugh: So we've talked about three different cases today, and the specialties and the procedures involved in all those cases are very different. But there is a common theme running through all of these. And that is that information was obtained, it was placed in the medical record... whether it was a test result or a questionnaire, all of the information in these three cases was actually in the patient's chart. It was in the medical record, not lost, not filed to the wrong chart, but it was actually in the chart. It just wasn't acted upon. 

And so in all three of these cases, the information was critical to the rendered treatment. This is not just side information that may or may not have an impact on the patient's treatment. This was very critical information that was in the patient's chart. And unfortunately, it was not acted upon. And so in all three of these cases, the information was not reviewed, and unfortunately, in all three cases, it led to very devastating consequences. You know, one thing that we hear a lot is, "If it's not in the chart, it didn't happen."

Katy: Yes.

J. Baugh: And that's used a lot to ensure that our physicians are very thorough in documenting the care that they render to the patient. If it's not in the chart, it didn't happen. Well, I think the flip side of that coin is also true. If it's in the chart, it's assumed that the doctor knew it was in the chart and that the doctor would have that information and would be able to act on it. So, "If it's not in the chart, it didn't happen," is true, and it's also true that if it is in the chart, the doctor is responsible for knowing it and being able to act upon it.

Katy: I agree completely. And in our first and our third cases, we have situations where the test results were placed unread in the patient's chart. J, you already discussed this, and that is a great point about reviewing your systems. Make sure that does not happen. You are going to be held responsible for all of the information that's in your chart if you're defending your care in a lawsuit. So you need to make sure that you see all that information before it goes in.

And our second situation has a slightly different wrinkle about information that was not read by the doctor. This is information that comes directly from the patient. Myself as a patient, I've filled out plenty of patient intake forms. They asked me to provide certain information. If that form is important enough for you to have your patient complete, then that form is important enough for you to read. Because the critical piece of information that you need to care for them may be provided there.

J. Baugh: That's right. We often hear, "If you ordered a lab, then it's important enough for you to have read the results of the lab."

Katy: Right.

J. Baugh: And so if you've got any kind of information at all that's in the chart, you're responsible for knowing it. You can't argue that, "I've been seeing the patient for so long that there's so much information in the chart." You've got to know everything that's in there. And you do need to review your processes to ensure that you don't have a situation like this where information gets in the chart and no one has reviewed it.

Katy: Right.

J. Baugh: So Katy, thank you for being here with us today to discuss these three closed 

Katy: Thanks, J. It's been a pleasure.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.