In defending medical malpractice cases, we are often faced with issues pertaining to the accuracy of the medical records.  It was originally thought that Electronic Medical Records (EMR) would provide a completely accurate contemporaneous record of what occurred in the medical care.  Unfortunately, EMR is only as good as the efforts used to correctly input the data.  Even the slightest discrepancy or ambiguity may result in protracted litigation.

In the recent case of Evans vs. Freedom Health Care, LLC (2022), it was alleged the health care providers were negligent in providing injection therapies to treat a patient suffering from knee joint pain.  After several injections, the patient began experiencing worsening knee pain.  He was diagnosed with a severe septic knee infection requiring a prolonged hospitalization and multiple surgeries on the affected knee.

The health care providers asked the trial court to throw the case out based on evidence that a joint infection can occur even if the health care provider was not negligent.  The patient provided no admissible expert testimony to the contrary.

No so fast.  The Nebraska Supreme Court reversed that decision and sent the case back to the trial court for a jury trial.  One of the main reasons the Court reversed was because there was a discrepancy in the EMR as to whether the patient received one or two syringes of medicine at the time of the injections.  As a result, the Court determined there could be an inference of negligence based on how many syringes were actually used such that the trial court should not have dismissed the case.

What is the takeaway?  The EMR must be consistent and accurate.  In this case, there was  differing documentation as to how many syringes were used.  That, in and of itself, resulted in the litigation going from being thrown out, to a case going to a jury trial in which the health care providers must sit through the anxiety and uncertainty of our judicial process.