In This Article
Mike’s Quick Answer
Electronic medical records can improve communication and make information easier to retrieve, but they also create predictable pitfalls. Templates may insert normal findings that were never tested, copy an old complaint forward, carry the wrong side of the body, repeat an outdated medication list, or make every visit look identical. Dropdown choices can flatten a complicated answer into one word. Patient portals may show only part of the chart. In an injury case, a record should be read as a clinical document created inside a software workflow, not as a perfect transcript of everything said and done.
Copy-Forward Can Preserve Errors
Clinicians often begin with a prior note to save time. If an earlier entry says left shoulder when the problem was right, or says symptoms are unchanged after they improved, the error can repeat across months.
Repetition can make a mistake look more authoritative. Comparing the note with imaging orders, examination, treatment, messages, and later corrections can reveal what actually happened.
A Template Can Be Longer Than the Visit
An electronic examination may list many normal systems with one click. That does not necessarily mean every item received a separate detailed test. Conversely, a short note may omit a complaint that the provider considered but did not type.
The note’s purpose, specialty, billing requirements, and workflow matter. A physical therapist, emergency physician, radiologist, and surgeon document different questions.
The Visible Chart May Not Be the Whole Record
Audit trails can show who entered, viewed, changed, or signed information and when. Portal messages, questionnaires, scanned documents, images, flowsheets, orders, and metadata may sit in separate parts of the system.
An ordinary records request may produce a summary without every electronic component. I ask for additional material only when a real discrepancy makes it relevant, rather than turning every case into a software audit.
Correct Errors Through the Proper Process
A patient can raise a material error with the provider and request an amendment under the office’s procedure. A proper amendment preserves the original and adds a dated correction or explanation.
Do not ask a provider to rewrite history for litigation. I address ordinary shorthand through context and testimony. Audit evidence is reserved for a significant authenticity or alteration issue, not every imperfect sentence.
Frequently Asked Questions
Does a copied medical note make it false?
Not automatically. Copy-forward can be accurate or inaccurate. Compare individualized findings, changes, orders, and the provider’s explanation.
Can I ask to correct my medical record?
Yes. Use the provider’s amendment process. The original generally remains, with the requested correction or response documented.
Can a lawyer obtain the EMR audit trail?
Potentially when relevant and available through authorization or discovery. Its scope should match a genuine timing, access, or alteration issue.
Sources and Further Reading
About Michael B. Fusco
I am Michael B. Fusco, a New Jersey personal injury lawyer who is Certified by the Supreme Court of New Jersey as a Civil Trial Attorney. For more than 15 years, I have represented injured people throughout New Jersey and have recovered more than $75 million in gross settlements and verdicts. I started Fusco Law because clients deserve direct answers, careful preparation, and a lawyer who remains personally involved. I can help guide clients through the complexities of a New Jersey personal injury case from the first investigation through settlement or trial. Past results do not guarantee future outcomes.
A Medical Chart Is a Database, Not a Dictation of Your Life
When a copied or coded entry changes the meaning of the case, it deserves a careful, proportionate response. Contact Fusco Law or dial 732-INJURED so I can place the record in its proper clinical context.
Important Disclaimer
This article provides general information only. It is not legal advice, and it does not create an attorney-client relationship. Contacting Fusco Law does not create an attorney-client relationship or make a communication privileged unless and until the firm agrees in writing to represent you. I am a personal injury attorney, not a medical doctor, accountant, tax adviser, or financial adviser. Medical, tax, accounting, and financial questions should be directed to an appropriately licensed professional. Every matter depends on its own facts and the law that applies. If you have questions about a New Jersey personal injury claim, contact Fusco Law.