For decades Healthcare records has been one of the only documents who do not bear the burden of "the truth, the whole truth, and nothing but the truth".
By federal and state law, these documents are entered into court as evidence as the exception to the hear-say rule. In a nutshell .."If it is not documented, it did not happen,.... If it is documented, it did happen" all while offering no mechanization to prove either is true.
Omissions of material fact are commonplace, editing, altering, deleting of records are not uncommon. Is it any wonder botched medical care has become the number three cause of death in America, and many more left crippled for life, . Today less than 1/2 of 1% of victims are ever compensated for pain and suffering, providers are rarely reprimanded and nothing is learned to keep the same harm from happening to others. The cycle of patient abuse continues over and over.
Today, informed consent is only a passing conversation in many medical schools, often it is simply called "consent the patient", meaning get the signature. Many times that signature is the day of surgery, long after the patient has mentally accepted risks never mentioned.
- On average 10% of diagnosis are wrong to start with.
- Double booking of surgeries is common, meaning your trusted surgeon may not even be in the operating room with you.
- On average 1 out of 4 patients will experience botched medical care, half of those serious including death.
- Surgeons are not required to document when they enter or exit your operating room, or if they even did.
- The odds of any surgeon being held accountable for patient harm or death is near zero.
- Hospital associations continue to fight patient's requests for elective audio/video of surgery to ensure patients get what they consented to.
Next week: Altering electronic medical records.