The Role of Hospital Record Keeping in Denver Medical Error Cases
In the aftermath of a serious medical error, accurate documentation becomes critical to uncover what happened, why it happened, and who is responsible. But what happens when those records are inaccurate, incomplete, or they have been suspiciously altered?
The Denver hospital malpractice lawyers at Leventhal Puga Braley P.C., have built our reputation as one of Colorado’s top medical malpractice firms by successfully challenging hospitals and health systems in high-stakes cases. We understand the central role that hospital record keeping in medical error cases plays in litigation, and how to expose problems when records don’t match reality.
Why Hospital Records Matter in Medical Malpractice Claims
When you file a lawsuit after a medical mistake, a major part of your case is built on what the records show. Hospital charts, progress notes, test results, and medication logs provide a timeline of care. They help establish:
- What the care team knew and when
- Whether symptoms were monitored and documented
- What decisions were made, and by whom
- Whether hospital protocols and standards were followed
Types of Hospital Record Keeping Errors
Common hospital record keeping errors include inaccurate, incomplete, or misleading documentation. These are often cases where bad documentation hides bad care, and unearthing those flaws becomes essential to exposing the truth.
This includes situations where:
- Important information is missing from the record (e.g., vital signs, nursing observations)
- Conflicting notes suggest negligence (e.g., one nurse documents patient pain, another says “comfortable”)
- Entries are added late, altered, or backdated, possibly to cover up mistakes
- Diagnostic results or physician instructions were never recorded or communicated
What to Look for in a Medical Error Investigation
When we investigate a potential malpractice case, we conduct a forensic review of all available records.
Time-Stamps and Order of Entries
Modern electronic health records (EHRs) automatically log when notes are made. We look for:
- Notes entered after a critical event but backdated
- Delayed documentation of test results
- Inconsistent time-stamps between systems (e.g., nurse’s log vs. medication administration record)
These inconsistencies may point to a medical defense strategy built around an after-the-fact justification, rather than real-time care.
Altered or Incomplete Entries
When something goes wrong, records may be quietly edited. We often see:
- Deleted entries replaced with new language
- Addenda added without explanation
- Unusual gaps in the timeline
Hospitals are required to follow strict protocols when editing charts, including preserving original versions. If records are altered improperly or without notification, it can indicate a concealed hospital error.
Nursing Notes and Communication Logs
Nurses play an integral role in delivering patient care. Their documentation often provides the clearest picture of what happened moment-to-moment. We look for:
- Notes about vital signs, pain, medication reactions, and alarms
- Internal communications with physicians or other staff
- Missed opportunities to escalate care
If staff noted a problem but nothing was done, or if the concern wasn’t documented at all, it can be powerful evidence of systemic breakdown.
Inconsistencies Between Records and Witness Statements
Sometimes the record says one thing, but a doctor or nurse later testifies to something else. In deposition or trial, we cross-reference testimony with the chart to reveal:
- Memory errors or omissions
- Conflicting accounts of key events
- Gaps that may reflect defensive documentation
How We Challenge Problematic Medical Records
Leventhal Puga Braley P.C. uses meticulous research to expose medical chart discrepancies and challenge hospital records that don’t align with reality. Here’s how:
Demanding the Full Audit Trail
Hospitals must maintain audit trails of electronic records. These are logs that show when entries were created, edited, or deleted. We collect this data to track:
- When each note was entered
- Who accessed the record
- What changes were made and when
This allows us to determine if someone altered the chart to avoid liability and to hold them accountable.
Working with Medical Experts
We retain top-tier physicians, nurses, and hospital administrators to review documentation and help us explain complicated issues to a jury, such as:
- What should have been charted based on protocols
- How errors or omissions deviated from standards
- Whether gaps in care were covered up
Depositions of Care Providers
Through detailed depositions, we uncover:
- Staff training (or lack thereof) on documentation protocols
- Internal communications not reflected in the chart
- Attempts to retroactively justify poor decisions
We use inconsistencies to challenge the credibility of those involved and establish a narrative of negligence and concealment.
What You Should Do If You Suspect a Hospital Error
If you or a loved one suffered a serious medical complication and you suspect that something went wrong, take these steps right away:
- Document Everything You Remember: Dates, times, names, and conversations can be valuable later.
- Do Not Rely on Hospital Explanations Alone: Hospitals often conduct internal reviews, but those are not impartial.
- Speak with an Experienced Denver Medical Malpractice Attorney: A qualified legal team can review the records and determine whether poor documentation is covering up a larger problem.
Why Choose Leventhal Puga Braley P.C.
If a hospital fails to document care correctly, or if they manipulate the record after the fact, the people in charge must be held accountable in court. Leventhal Puga Braley P.C., is nationally recognized for our success in complex medical malpractice cases. Our attorneys work with leading medical experts and forensic specialists to build compelling cases based on facts.
Speak With an Experienced Denver Hospital Malpractice Attorney Today
If you suspect that inadequate or altered hospital records played a role in a loved one’s injury, disability, or death, don’t wait to act. Time matters, and records can become harder to access the longer you wait.
Call Leventhal Puga Braley P.C. today at (303) 759-9945 or (877) 433-3906, to schedule your initial consultation at no-charge.
We’ll review your case, examine the medical documentation, and fight to uncover the truth.