Why Documentation Matters in Medical Malpractice Claims
Medical negligence can rob you of time with loved ones, forcing you to deal with physical limitations and psychological distress. A patient’s medical records serve as the cornerstone of a medical malpractice case, with missing information strengthening a plaintiff’s case. Detailed medical records (along with expert witness testimony) allow a jury to understand the progression of a patient’s case, from presentation of symptoms to treatment.
Providing the insurance company with the requested documentation and meeting court deadlines are no easy tasks. If you have been harmed due to a physician’s incompetence, our Cherry Hill medical malpractice lawyers are here to assist you in filing your claim.
To Prove Lack of Informed Consent
Patients have a right to make decisions over what happens to their bodies, known as patient autonomy. A patient can only make educated decisions when they understand the known risks and benefits of a procedure, as well as alternative treatment options. This is known as informed consent. It is crucial that a physician document informed consent before a procedure. If a patient refuses care, this should be documented as well.
Common procedures that require informed consent include:
- Invasive procedures, such as colonoscopy and endoscopy
- Procedures involving the administration of anesthesia or conscious sedation
- Biopsies
- Cancer treatments, such as chemotherapy and radiation
- Childbirth interventions, such as forceps delivery and episiotomy
- Clinical trials
- Genetic testing
- Medical implants
- HIV testing
- Treatments with high-risk medications, such as opioids
If your provider failed to inform you of the known risks of a procedure and you suffered harm, you may have a medical malpractice claim. It is a physician’s responsibility to get your informed consent, not that of the medical staff. However, you must show that knowing about the risk would have stopped you from having the procedure. Claims based on lack of informed consent require obtaining signed consent forms. Our legal team will look for missing information or forms that are missing your signature.
To Show Misdiagnoses or Delayed Diagnoses
Misdiagnosis occurs when a physician fails to diagnose a condition. A delayed diagnosis occurs when a condition is diagnosed at a later stage, when a disease or ailment has time to progress. A misdiagnosis may occur due to misinterpreting test results or imaging, failing to take a complete history, or failing to order appropriate testing. Accordingly, evidence often includes medical imaging, laboratory testing, biopsies, clinicians’ notes, and expert witness testimony.
To Demonstrate Inconsistency in Care
If multiple providers are involved in a patient’s care or if a patient handoff occurs (like in a hospital setting), there may be incongruencies in treatment. Physicians should coordinate care between other providers, whether that means reviewing another clinician’s notes or discussing a patient’s status during a handoff (a hospital shift change). Treatment plans, nurses’ notes, and progress notes can show discrepancies in treatment. However, be aware that the insurance company may find you partially liable for your injuries if your records show gaps in treatment (due to you missing doctor’s appointments).
Cost to Obtain Medical Records in NJ
Under NJ Rev. Stat. § 45:9-22.27, a healthcare provider is allowed to charge $1 per page and $50 for the entirety of a patient’s medical or billing records. When you have hundreds of pages of medical records, this can be costly. There are ways to get around these fees, including requesting the records in digital format. At Ginsberg & O’Connor, our Cherry Hill medical malpractice team is dedicated to finding the truth, not letting inconveniences get in our way.
Speak with Our Cherry Hill Medical Malpractice Attorneys Today
If you have experienced medical negligence, now is the time to contact Ginsberg & O’Connor. With over 40 years of advocating for injured individuals, our Cherry Hill medical malpractice lawyers know which evidence to obtain and how to get it. To learn the true value of your accident case, contact us online or call (856) 727-1991 to arrange your free consultation.