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Poor Record-Keeping Leading to Medical Malpractice

Syracuse Lawyers for Patients Injured by Negligent Health Care Providers

Doctors and other health care providers must properly document and record their caregiving while diagnosing and giving care. Medical record-keeping allows a doctor to establish that treatment was appropriate and also administered properly. Moreover, record-keeping is essential to proper patient management and avoiding injury to the patient. Sometimes poor record-keeping that causes harm to patients and constitutes medical malpractice. The Syracuse medical malpractice attorneys at DeFrancisco & Falgiatano may be able to help you recover damages if you have suffered injuries under these circumstances.

Poor Record-Keeping Leading to Medical Malpractice

Health care providers are supposed to properly document the management of a patient. Medical records can include documents about a patient’s medical history, medications, test results, clinical findings, operation notes, nursing care notes, lab data, pharmacy records, post-operative care notes, and daily notes about how a patient is progressing. This documentation can also be used as evidence in case of a medical malpractice lawsuit. Poor record-keeping might involve an improper operation note, an illegible drug prescription, or a prescription without a date. Additionally, however, when documentation and record-keeping deviates from the professional standard of care for these practices, serious harm can ensue.

Liability for Poor Record-Keeping

If you believe poor record-keeping led to medical malpractice in your case, you may be able to recover damages. To be successful in a lawsuit, you will need to show: (1) you were owed a professional standard of care by the defendant(s), (2) breach of the professional standard of care, (3) causation, and (4) damages. The professional standard of care is the accepted standards and practices of health care providers in the same specialty and geographic location when faced with a similar patient. The medical community has certain professional standards for record-keeping, and it’s important that your health care provider follow them.

Failure to keep proper records may be the result of negligence. A health care provider may find it time-consuming to be diligent in taking notes, and doctors practice medicine for long, stressful hours. In some cases, staff members fail to keep proper records or fail to note an important piece of information. There may be inconsistencies that make it difficult for a health care provider to keep track of whether he followed up on an important lab test result, or prescribed a vital medication. If, for example, your doctor didn’t keep notes about taking you off a dangerous medication about which an FDA warning has been issued, this could result in you continuing to take the dangerous medication and suffering serious side effects. For another example, if your doctor fails to write down a critical aspect of your patient history, he might not create a proper differential diagnosis list, and may miss the actual diagnosis of your symptoms. This could result in you getting an improper treatment that causes you injuries, while your underlying medical condition progresses and worsens. A knowledgeable medical malpractice lawyer can review the facts of your case to assess whether you may have a valid claim.


If you can establish liability for medical malpractice arising out of poor record-keeping, you may be able to obtain compensatory damages. These are damages intended to put you back in the position you would have been in had there been no malpractice. The amount of damages available in a given case depends on the extent of injuries arising out of the medical malpractice. They can address both economic and noneconomic losses. Economic losses may include the costs of medical care needed to address the injury caused by malpractice, lost wages, replacement services, and out-of-pocket costs. Noneconomic losses are usually intangible losses such as pain and suffering, mental anguish, loss of enjoyment of life, and loss of consortium.

Consult an Experienced Medical Malpractice Attorney in Syracuse

It is vital that hospitals and health care providers keep good records and provide you with competent care. If you were injured and suspect poor record-keeping leading to medical malpractice in Syracuse, you can discuss your situation with a skilled medical malpractice attorney. At DeFrancisco & Falgiatano, we represent people in Syracuse, Rochester, and throughout Upstate New York, including in Lowville, Watertown, Utica, Wampsville, Oswego, Elmira, Cooperstown, Canandaigua, Lyons, Binghamton, Oneida, Ithaca, Auburn, and Herkimer. Call our firm at 833-200-2000 or contact us via our online form.

Client Reviews
"We were very impressed with how Jeff DeFrancisco represented us at trial and we were extremely happy when the jury found in our favor." D.M., Auburn, NY
"I suffered a serious injury as a result of medical malpractice. My husband and I retained Jeff DeFrancisco to assist us in this case. We were extremely happy with his representation and highly recommend him." Kelley R., Syracuse, NY
Since the insurance company was unwilling to settle the matter my case ultimately went to trial. At trial Jeff DeFrancisco did an absolutely amazing job by obtaining a very favorable result for me." T.H., Oneida, NY
"I highly recommend DeFrancisco & Falgiatano - Charlie represented me for a medical malpractice case. He is the best of the best. He is friendly and I am very happy with the representation he provided." Roger N., Oneida, NY