Failure to Take the Patient's Medical History

Patient history and patient records are crucial for doctors to provide the best care. When physicians and medical staff do not record patient history or fail to take it into account when seeing a patient, the results can be disastrous. It happens all too often, and in fact, a recent study found that over five years, nearly 2,000 patient deaths were related to communication errors, accounting for nearly a third of malpractice cases. Doctors need to include patient history in decision-making because it directly impacts the diagnosis they give and the treatments they chose to best help the patient. If you feel you suffered because your doctor disregarded your medical history or that someone made a mistake in recording your medical history, contact our medical malpractice lawyers at DeFrancisco & Falgiatano to help you determine if you have a case for compensation.

Obtaining a medical history can reveal the relevant chronic illnesses and other prior diseases for which the patient may not be under treatment but may have had lasting effects on the patient's health. In general, a medical history includes an inquiry into the patient's medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking. A complete medical history includes a more in-depth inquiry into the patient's medical issues which includes all diseases and illnesses currently being treated, and those which have had any residual effects on the patient's health. Surgical history includes all invasive procedures the patient has undergone. Family history is another aspect of the patient's medical history with potential indicators of genetic predisposition to a disease. Social history is a broad category of the patient's medical history but may include the patient's smoking or other tobacco use, alcohol, and drug history and should also include other aspects of the patient's health including spiritual, mental, relationship status, occupation, hobbies, and sexual activity or pertinent sexual habits. Accurately documenting the patient's medical history can be lifesaving as well. An encounter with a patient who can answer all questions which are subsequently recorded on the electronic medical record could prove to have vital information in the event the patient's mental status changes, or during a later encounter if the patient is unable to give their history such as in a traumatic accident.

Any action or inaction on the part of a physician or other medical staff that constitutes a breach in duty of care and causes harm and significant damages to the patient may be considered negligence and may lead to a successful medical malpractice case. In instances that involve the patient's record and medical history, it must be proven that there was a duty of care between the doctor or medical facility and the patient. The case must then prove that the mistake constituted a breach in care, that it resulted in harm to the patient, and that the harm caused damages. The consequences of making errors in patient records and ignoring or disregarding them can be very serious. These mistakes can lead to a failure to diagnose a patient correctly, errors in medications, and failure to provide the best treatment. These in turn may lead to ongoing symptoms, worsening illnesses, additional illnesses, a need for more treatments and more invasive treatments, additional medical bills and expenses, loss of wages, pain and suffering, and many more potential consequences. A physician's failure to chart their patient's medical history can cause a host of problems such as an inappropriate medication being prescribed. That failure could mean medical malpractice occurred. If a doctor has failed to take your medical history, then he or she may prescribe a medication that you may be allergic to or conflicts with other medications that you are currently taking. It can also result in misdiagnosis or failure to diagnose a condition. A doctor's failure to check his or her patient's medical history can result in the patient being diagnosed with the wrong disease. In other cases, it can result in someone not receiving their diagnosis early enough. Depending on the situation, this can limit treatment options or cause more harm to the patient than would have been necessary.

If you or someone you love has suffered harm because of negligence by a primary care or family practice care provider, our attorneys may be able to help you recover damages from the responsible parties. DeFrancisco & Falgiatano are experienced medical malpractice lawyers that represent people in Syracuse, Rochester, Lyons, Ithaca, Cooperstown, Oswego, Canandaigua, Utica, Wampsville, Oneida, Lowville, Watertown, Herkimer, Delhi, Cortland, Norwich, Elmira, Auburn, and Binghamton. Call us at 833-200-2000 or contact us via our online form.