Negligence and Health Records

Negligence and Health Records

1. Explain the four elements of negligence that must be present in order for a plaintiff to recover damages?
2. Discuss the purposes for which the health record is maintained within a healthcare organization.
3. Explain the concept of e-discovery and discuss the role of health information management professionals in the e-discovery process.
4. What are the differences between a living will and a durable power of attorney for healthcare?
5. The corporate director of risk management is asked to review a patient’s health record in preparation for legal proceedings for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being non-compliant with the organization’s record completion policies, and previous concerns regarding this physician’s record maintenance practices had been reported to the organization’s credentialing committee.
   1. Apply appropriate legal concepts to demonstrate why this health information may not be admissible in court.
   2. What judgment, if any, regarding negligence could be made against the organization?

• Explain the four elements of negligence that must be present in order for a plaintiff to recover damages?,

• Discuss the purposes for which the health record is maintained within a healthcare organization?,

• Explain the concept of e-discovery and discuss the role of health information management professionals in the e-discovery process?,

• What are the differences between a living will and a durable power of attorney for healthcare?,

• Apply appropriate legal concepts to demonstrate why this health information may not be admissible in court, What judgment, if any, regarding negligence could be made against the organization?

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Comprehensive General Answer

1. Four Elements of Negligence

For a plaintiff to recover damages in a negligence claim, all four legal elements must be proven:

1. Duty of Care:
   The defendant (e.g., a healthcare provider) must owe a legal duty to the plaintiff (patient). In healthcare, this arises from the provider–patient relationship, obligating the provider to act in accordance with accepted medical standards.

2. Breach of Duty:
   The provider must have failed to meet the standard of care expected of a reasonable professional in similar circumstances. Breach occurs when the provider’s actions (or inaction) deviate from what a competent provider would do.

3. Causation:
   There must be a direct link between the provider’s breach and the patient’s injury. The plaintiff must prove both actual cause (“but for” the defendant’s action, harm would not have occurred) and proximate cause (the harm was a foreseeable result of the breach).

4. Damages:
   The plaintiff must have suffered measurable harm—physical, emotional, or financial—resulting from the breach. Without actual damages, even a proven breach does not result in recovery.

If any of these four elements is missing, a negligence claim will fail.

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2. Purposes of the Health Record in Healthcare Organizations

A health record serves multiple critical purposes, including:

• Patient Care: Provides an accurate, continuous record of diagnosis, treatment, and progress to support ongoing care and coordination among providers.

• Legal Documentation: Acts as a legal record of the care provided, supporting the defense in malpractice claims and regulatory investigations.

• Billing and Reimbursement: Supplies necessary data for accurate coding, billing, and insurance claims.

• Quality Improvement and Risk Management: Enables analysis of outcomes, identification of trends, and development of policies to enhance safety and quality.

• Research and Education: Offers data for clinical studies and training future healthcare professionals.

A complete, timely, and accurate record is essential for both clinical and legal integrity.

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3. Concept of E-Discovery and HIM Role

E-discovery (electronic discovery) refers to the process of identifying, collecting, preserving, reviewing, and producing electronically stored information (ESI) for use in legal proceedings. This includes emails, electronic health records (EHRs), audit logs, and metadata.

Health Information Management (HIM) professionals play a vital role by:

• Ensuring legal hold is placed on relevant records to prevent deletion or alteration.

• Maintaining data integrity and authenticity of EHRs and metadata.

• Coordinating with legal teams and IT to retrieve and produce records in legally compliant formats.

• Ensuring privacy and security of protected health information (PHI) under HIPAA during the discovery process. Negligence and Health Records

Their expertise ensures that electronic health data is properly preserved, traceable, and admissible in court.

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4. Living Will vs. Durable Power of Attorney for Healthcare

Both are forms of advance directives ensuring that patients’ wishes are respected when they cannot communicate.

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5. Legal Concepts and Admissibility of Health Information

In the malpractice case scenario:

• The procedure summaries were dictated 95 days after the procedures, well beyond normal documentation standards.

• This delay undermines the authenticity, reliability, and trustworthiness of the health record.

• Under rules of evidence, medical records must be created in the ordinary course of business and at or near the time of the event to qualify as admissible business records.

• Since these entries were delayed and the physician had a history of noncompliance, opposing counsel could argue that the records were altered, reconstructed, or unreliable, leading to inadmissibility in court.

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