Most professionals who are defendants in a lawsuit will soon learn that the success of their litigation could rise and fall on the quality of their record keeping. The differences of opinion will turn on what was intended by the notations in the professional records versus what the notations actually reflected.  At trial or even before a professional licensing board, a legal defense team may have difficulty convincing a jury that just because an action was not recorded, the action still occurred.
 
For health care providers, medical records of patients’ care will become the subject of heightened scrutiny in a trial for health care provider liability. One medical expert testified during a recent trial that physicians keep medical records so that other providers can track a patient’s care, but that the records were not kept for the purposes of satisfying lawyers at trial.  Despite the truth in his statement, good record keeping will not only improve accountability on the job, but it may help win a trial. Further, while poor record keeping is a common accusation against medical professionals, other professionals like accountants are just as accountable for their record-keeping practices.
 
No matter what the profession is or whether records are paper, electronic, handwritten, clinical notes, emails or letters, the most common record-keeping mistakes outlined below, if avoided, could make the difference at a trial for professional liability.

• Lack of clarity such as “patient had a good day” or “patient slept well”
• Failing to record an action taken once a problem is identified and recorded
• Missing information such as failing to record administering a drug
• Inaccurate records such as recording treatment that was not received
• A misplaced comma or period in writing a dollar amount, which could lead to an unintended windfall
• Failing to record conversations or agreements
• Making record notations too long after the action was taken so that items are forgotten
• Failing to define key terms or conditions in a contract

Avoiding these record-keeping mistakes may not avoid a law suit entirely, but good record-keeping practices could convince a jury or a professional board that the services rendered were just as good as the records reflect.

John D. Martin is a trial lawyer and the managing partner of the Cranfill Sumner & Hartzog LLP’s Wilmington, North Carolina office. Martin concentrates his practice in the medical malpractice and professional liability defense practice groups.  He has tried numerous medical malpractice and personal injury cases throughout eastern North Carolina. Many of his cases involve brain injury, birth trauma, paraplegia and wrongful death. Additionally, Martin has experience with large construction litigation, premises liability and hospital/workplace security. To contact Martin, call (910) 777-6018 or email him at [email protected].