Electronic medical records need to be read in context
Electronic medical records bring information from many visits into one system. That can help providers follow care, but a particular entry may still need explanation. A copied history or a short menu selection may not describe everything discussed at an appointment. I read the individual note alongside the surrounding record before deciding what it establishes.
A careful reading of the full record helps make sure the person behind the chart is understood. If an insurer relies on a sentence that seems inconsistent with your experience, the next step is to examine where it came from and what other information may clarify it.
A repeated entry may reflect the way the system works
Some systems allow a provider to carry information forward from an earlier visit. That can preserve useful history. It can also carry an outdated item into a later note. The fact that a statement appears several times does not answer whether it was reconsidered each time.
Suppose a note describes the left shoulder while the examination and imaging concern the right shoulder. The proper response is to compare the entries and seek clarification where needed. It would be premature to treat that inconsistency as proof that the patient described a different injury.
At the same time, we should not assume every inconvenient entry is a mistake. I want to understand the original information, the purpose of the note and any explanation the provider can give. A careful review protects the claim by separating a genuine conflict from shorthand that looks different when taken out of context.
The patient portal may show only part of the picture
What you can see in a portal may not be the complete record maintained by the provider. There may be separate questionnaires or messages, and imaging may be stored outside the note itself. If an issue depends on the sequence of events, those materials may be important.
Save relevant portal messages in their original form where possible. A message asking about a delayed referral can help explain an interval between visits. A message reporting a new symptom may help establish when it was brought to the office’s attention. The date and the response can matter as much as the text alone.
Your lawyer can request appropriate records through authorization or the litigation process. The scope should fit the issue. We do not need every technical component of a hospital system to answer a simple date question, but we should not assume a brief visit summary contains all available information either.
Ask about a material error promptly
If you see something that appears inaccurate, contact the provider and ask about the amendment process. Identify the specific entry and explain the factual concern. Under HIPAA, patients have rights to request amendments from covered entities, subject to the rule’s requirements. If the request is denied, a statement of disagreement may become part of the record.
Keep the original entry and the correspondence about the request. A proper correction should be understandable as a correction, not an unexplained replacement. Tell your lawyer if the issue affects the injury claim so we can account for both versions and the provider’s response.
This process should focus on accuracy. A provider may disagree with your understanding of a medical finding, which is different from having entered the wrong date. Ask for an explanation of the distinction. Your lawyer can evaluate the legal effect while the provider addresses the medical or documentation question.
Timing can require more than the printed note
In some cases, when an entry was created or changed becomes relevant. Electronic systems may retain audit information identifying actions within the record. Whether that information exists and can be obtained depends on the system, the request and the applicable legal process.
An audit trail requires careful interpretation. A timestamp may reflect a signature or a later administrative step rather than the time of the examination. Technical information should be evaluated with an understanding of the system before anyone draws a conclusion about what it means.
I pursue that level of detail when it can answer a material question. For many cases, comparing the clinical notes and asking the provider for clarification is sufficient. The investigation should be proportionate to the issue rather than turning a minor inconsistency into an unnecessary dispute.
Explain your history in your own words
You can help by telling the provider what changed and by identifying any concern you notice in the record. You do not need to adopt the terminology of the electronic form. A clear description of your symptoms and daily limitations gives the provider better information to work with.
When I review electronic medical records, I consider how the history fits with the examinations and the course of treatment. The record should be part of an explanation of your injury, not a collection of isolated phrases. If something needs context, we identify what would supply it and work toward a fair account of the evidence.
Bring a concerning entry to your lawyer’s attention rather than assuming it decides the case. A focused review may show that the surrounding records already explain the issue. Where more information is needed, we can determine the appropriate next step without losing sight of the actual injury and recovery.
Sources and Further Reading
About Michael B. Fusco
Michael B. Fusco is a New Jersey personal injury attorney certified by the Supreme Court of New Jersey as a Civil Trial Attorney. Read Mike’s biography and credentials.
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General Information
This article provides general information, not legal advice for a particular situation. Laws and policy terms must be applied to the actual facts. Reading this article or contacting the firm does not, by itself, create an attorney-client relationship.