As most medical malpractice practitioners know, the patient’s chart is the foundation on which a professional liability case is built or defense razed, and the procurement of the complete medical record is a priority for both the patient and the defendant health care provider. Until recently, not much had changed with respect to the creation, preservation and production of medical records. Medical records have been on paper for centuries, and if a patient’s chart is requested, it would be physically maintained in storage for retrieval.
However, the rapid nationwide push for an integrated electronic medical record (EMR) system has changed all of this. Signatures have been replaced by sign-ins, charts are stored electronically and documentation is by keystroke instead of pen to paper. The law simply has not had enough time to keep up with these changes, and there is a dearth of legal precedent on how to handle EMR production and preservation issues in the context of medical malpractice litigation. Looking forward, there are ways to streamline medical malpractice discovery issues pertaining to EMRs to limit court involvement and keep costs in check.
