Portland, OR asked in Medical Malpractice for Oregon

Q: Yes I was wondering if false documentation on a medical record from a physician is something to pursue

There is no expectations or pain contracts set in place therefore I was unaware of the rules

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2 Lawyer Answers
Patrick D. Angel
Patrick D. Angel
  • Medical Malpractice Lawyer
  • Lake Oswego, OR
  • Licensed in Oregon

A: Regarding the question as to whether false documentation on a medical record is something to pursue, the short answer is yes. You should always point out something inaccurate in your medical records if you notice it. It's just good practice and could protect you from harm, such as if the wrong blood type or wrong allergy is listed.

But it's not always so clear cut. Sometimes a note in your medical record is something the nurse or doctor remembers that happened and you don't, or vice versa. For instance, you may review your records and say, "I reported stomach cramps as one of my symptoms," but the chart does not indicate stomach cramps. Is that "false documentation?" Hard to say, the nurse or physician would likely say they would have wrote that down if you'd reported it. And it could be just a disagreement as to what symptoms were reported.

Regarding pain contracts, I'm not sure what the specific question is. It could be that a pain management specialist informs a patient that they violated the pain contract, as in when a patient takes more pain medication than was prescribed. In some instances the patient may say, "I don't recall discussing a pain contract." In that scenario, a patient can contact the physician and request the documents be amended/corrected, but it's unlikely to happen if the physician believes the discussion regarding a pain contract took place.

If you have additional questions, or something about this answer is unclear, let me know.

Take care and good luck with your medical treatment.

Virgil Royer and Tim Akpinar agree with this answer

Virgil Royer
Virgil Royer
  • Salem, OR
  • Licensed in Oregon

A: I agree with the previous response. Since it is unclear what you mean by "false documentation". I sincerely believe that you might find errors contained in almost any patient's file, such as a wrong birthdate, or height/weight, or someone's else name inserted. Nearly all of these are accidents and not done on purpose. If you notice an error, no matter how small, you probably should notify the medical office and have it corrected. If by false documentation, you mean, intentionally incorrect information (i.e., on purpose). Then, you really do need to figure out why it was placed in your file. As pointed out previously, healthcare providers are consistently on the look out for people that might be faking symptoms (called: "malingering"), or addicted to painkillers, etc, so they put notes in to remind themselves and inform others. There was a "Seinfeld" episode when one the main characters (Elaine) got labeled as a "difficult" patient making it impossible for her to get a new doctor. So, you do want to work any misunderstandings that you might have with your healthcare provider. Also, as noted earlier, you may want to discuss your matter with an attorney before you discuss anything with your provider to see if there are any other legal matters that might need to be addressed. I hope this helps you and that you are able to sort things out. Best wishes!

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