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From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: many of these issues are small, yet each issue is just that… an issue. If you take care of the small issues, then the larger issues often take care of themselves and you can focus on the larger issues… a larger, more profitable practice and more family time.

“Correcting the Incorrect Medical Report”

In the lawyer’s handbook that I have been referencing, there is a chapter on “Read and Understand All the Plaintiff’s Medical Records.” The author writes:

 
In preparing for cross-examination of the defense medical examiner, as well as the direct examination of your own experts, it is critical that you understand the medical records – what’s in them, what is not in them, what is correct and what is incorrect. Medical records are not gospel; in fact, they are frequently inaccurate and incomplete. If one Dr. enters incorrect information into a chart – even clearly incorrect information – Subsequent doctors will repeat it in their own notes until it becomes “Chart lore.” Your job as the attorney is not only to understand the medical records, but also the context of the information so that you can discern fact from fiction.

Over the last 35 years I can say with a great degree of certainty that between the ambulance report, police report, emergency room report, and various medical primaries and specialists that the common theme is inconsistencies in reporting an accurate history. Although this is something I’ve been cognizant of, it has been nothing more than a nuisance and what I often chose not to focus on other than getting the record corrected for my charts.

 
However, over the past year while presenting attorneys around the country I have been made acutely aware in virtually 100% of the conversations that this is significantly problematic for the legal community. In fact, this single item can help to undermine the entire medical legal process based upon a lazy Dr. or nurse in in previous medical settings. Therefore, it has become my job not to rewrite history, but to ensure its accuracy.
 
Prior to reading the lawyers manual I incorrectly thought the best way to fix the record is to send a copy of my record to the Dr. to ensure that an accurate version of notes was in that doctor’s record. However, the following is suggested by the lawyers:

 
Never asked the Dr. or nurse to change his or her records when you find a mistake. Rather, it’s best to have a patient send along a note correcting the error (in a non-judgmental way). The note then becomes part of the medical records.

 
In no way does this mean you should not send your records concurrently however, the courts consider the patient’s direct communication more so than a co-treating doctor.


 
Respectfully,



Mark Studin DC, FASBE(C), DAAPM, DAAMLP

Adjunct Assistant Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences 

 
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