Documentation errors

Malpractice claims and case studies alleging failure to create and maintain complete and accurate medical records.

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About Documentation Errors

Malpractice claims and case studies alleging failure to create and maintain complete and accurate medical records.

Failure to diagnose meningitis

A 20-month-old boy was brought to his pediatrician’s office with a one-day history of fever — up to 104 degrees.

Failure to obtain informed consent for tubal ligation

Good documentation by the physician and staff help disprove a patient’s claims

Failure to perform cesarean delivery

An ob-gyn encounters fetal macrosomia and shoulder dystocia

Failure to diagnose myocardial infarction

A patient leaves out details of his medical history while being treated in the emergency department.

Failure to respond to patient's symptoms

A patient reports pain and swelling following a vasectomy.

Failure to review radiology report

A 63-year-old woman came to her internal medicine physician reporting lower back and flank pain.

Performing an MRI when contraindicated

A general surgeon performed a left mastectomy on a 64-year-old woman

Failure to insist on EMS transport

A patient’s wife called her husband’s family physician because her husband was experiencing chest pain

Failure to stabilize a wrist fracture

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