Oh what a tangled web we weave, When first we practise to deceive! Sir Walter Scott.
Or, was it my partner Dan who said that about inconsistencies in medical records?
Like the time a nursing home nurse wrote that she was giving my client wound care at the nursing home on Wed., Thurs and Friday, when the client had been taken to the emergency room on Tuesday and died on Wednesday.
Or was it a client who said that when she requested her medical records and saw all of these entries that could not be true… like about her moving her arm when she was actually paralyzed.
I don’t think people often mean to deceive in their work. I don’t think doctors and nurses often purposefully try to change a medical records. More often I think we are rushed as individuals, and do not have time to observe and record with the level of dedication that is required by the task.
But regardless of the intent, often the outcome is the same.
A tangled web of inconsistent observations and recordings which could not actually be true.
That is why we always request the medical records first in a case. What do they say? Does everyone agree that Frank had a blue toe, or required wound care on his pressure ulcer? Did the doctor know about that?
We will do our best to untangle the web, and determine if legal action is recommended. And, we will do our best to read your records and understand what care and treatment was provided, when.