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How is Meaningful Information Extracted from Medical Records?

Uses of medical records can seem vague or unclear to many patients, especially when they have never actually looked at their own medical records themselves. The way in which healthcare providers obtain information from medical records, and the process by which physicians and specialists have access to a particular patient’s medical record can also be confusing, especially when you have moved from one location to another or have visited healthcare providers that are not within the same healthcare system or care group. 

When a healthcare provider makes a mistake by failing to properly attend to a patient’s medical record or fails to include or extract information from an electronic health record, that patient may be able to file a medical malpractice claim with help from a New York medical negligence attorney. 

Trusting Your Healthcare Provider to Learn Your Medical History

What are medical records, and how are healthcare providers supposed to use them? According to the American Medical Association (AMA), a patient’s medical records “serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes.” The AMA underscores that, in addition to ensuring that patient medical records remain confidential unless a patient expressly provides another party with access, “physicians [also] have an ethical obligation to manage medical records appropriately.”

What does it mean to manage medical records appropriately? In part, it means carefully extracting meaningful information from a patient’s medical record and using it to provide a patient with a high quality of care. In general, for a physician or other healthcare provider to extract meaningful information from a patient’s medical record, the healthcare provider must have access to accurate patient records and must know how to use or apply the information contained within them. 

How Medical Errors Can Result from Medical Record Mistakes and Inconsistencies

Many medical records are shifting to electronic health records (EHRs), but it is important for patients to know that medical errors and malpractice can still occur when EHRs are involved. According to, electronic health records are designed to provide healthcare providers with accurate and complete information about patients in a quick fashion, and in a format that is easy to share.

Indeed, EHRs are supposed to help physicians and other healthcare providers extract meaningful information more quickly and easily in order to “effectively diagnose patients, reduce medical errors, and provide safer care.” Yet, negligent behavior still occurs, and medical mistakes concerning health records result in patient harm.

Liability in a Medical Error Case Concerning Health Records

Who can be liable in a medical malpractice case where appropriate information contained in a patient’s medical record was not properly inputted, stored, received, or used by another healthcare provider? Depending upon the specific facts of your case, any of the following parties could be liable for medical malpractice:

  • Staff member who input medical information into a patient’s file manually and made a mistake;
  • Physician or nurse who input medical information into a patient’s file manually and made a mistake;
  • Facility (like a hospital) that failed to properly transfer a patient’s medical record to a specialist or a subsequent facility;
  • Company responsible for managing electronic health records;
  • Staff member responsible for handling electronic health records at a specific facility; and/or
  • Physician or other healthcare provider responsible for reading and interpreting a patient’s medical record.

While electronic health records are supposed to improve patient safety, mistakes can still occur in patient transfers, and even when healthcare providers are rushed. Those errors are avoidable, and a patient should hold the negligent party accountable. New York law gives most patients 2.5 years from the date of the error to file a claim for compensation.

Contact a Syracuse Medical Malpractice Attorney

Learning that you have suffered a serious injury or harm because of a mistake pertaining to your medical records can be devastating. Patients trust their healthcare facilities to ensure that accurate information is provided in their medical records, and they trust their physicians to pay attention to those medical records, reading carefully for any details that could impact their health. Yet mistakes pertaining to medical records get made much more often than many patients would like to consider. While meaningful information certainly can be extracted from medical records, there are various points at which negligence can result in a serious mistake that leads to a devastating patient injury.

If you suffered injuries because of medical negligence related to medical records, you should speak with a Syracuse medical malpractice lawyer about filing a claim for compensation. At Powers & Santola, LLP, we serve clients in Albany, Syracuse, and Rochester, New York. Contact Powers & Santola, LLP today to learn more about filing a lawsuit.

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