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Patient charts are key in malpractice cases

New Jersey residents might be surprised to learn that medical mistakes lead to roughly 250,000 deaths annually in the United States. In many cases, the cause of these errors can be ascertained by reviewing the clinical files of involved patients.

Determining the cause of an adverse medical event requires close scrutiny of the patient's clinical chart and other medical records. Unfortunately, reviewing records and determining the ultimate cause of an adverse medical event is made significantly more challenging when there is no clarity or consistency in the patient's clinical chart. If a nurse makes an error or omission in record keeping, it can lead to liability issues for the nurse and the facility.

One of the most common mistakes is the failure to record pertinent medical histories or drug information. This can lead to allergic reactions and other easily avoidable complications. Another frequent oversight is failing to timely record nursing actions or medications provided to a patient. Nurses sometimes feel pressured for time and put off some charting until the end of a shift. Keeping a precise chronological record is required, and delaying input can result in memory errors or inadequate data needed to provide proper care in the interim. Confusing patients and recording information on the wrong chart is another common error. In some cases, poor penmanship can have grave consequences.

Most medical mistakes can be prevented. Digital platforms can eliminate illegible handwriting while proper staffing can alleviate time pressures. Unfortunately, medical malpractice still exists in many forms. A lawyer with experience in the field could help a malpractice victim file a claim for damages.

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