Allergy Documentation Importance in Medical Malpractice Cases

The healthcare sector is not so easy as it was before. Today’s diseases and healthcare methodologies have become immensely complex to keep up with advanced and complicated diseases and situations we have today. Physicians today have to follow strict protocols before they even begin the healthcare service to a patient. Earlier days, people used to walk up to any general physician for their ailments and get treated. However, today things are more complicated.

We have different viruses, bacterias, and chemicals at play that did not exist 30-40 years ago. Hence, the patient needs to meet the right specialist to get the treatment they need and deserve. 

Sometimes, patients suffer because a doctor who is not a specialist for a particular ailment prescribes medicine without a medical history or disease history check. That severely affects the patient and may even lead to death. 

Medical Malpractice due to Allergic Reactions

In the USA alone, we see cases rising where patients lose their health or life due to an allergic reaction based on the prescribed treatment. As primary healthcare providers, it is the duty of the attending physician to ensure that they take all the relevant information from the patient before proceeding with the treatment.

This information could be in the form of an EHR report filed by the EMR team while transporting the patient via ambulance to the hospital or in an admit form through the medical history detailed there. 

The EHR forms and medical history forms are vital documentation to ascertain if there is 

  1. A history of allergic reactions due to certain medications to patients
  2. History of illnesses that may render the patient prone to allergic reactions
  3. If the above points are communicated to the physician entirely or not 

Any adverse reaction suffered by the patient from an allergic reaction during drug prescription or treatment amounts to medical negligence on the part of the doctor/hospital. The patient has every right to pursue a medical malpractice claim against them in such instances.

Proving your Allergy-related Medical Malpractice claim

Medical documents are your assets and weapons when it comes to fighting for your right in a medical malpractice suit against a hospital or a doctor. As a legal team, you must have all the facts, documents, reports, and summaries submitted by the physician team to present in court.

Often, the medical documents can seem heavy and difficult to understand for someone not actively working in the field. If we break down, some of the important medical documents in a medical malpractice suit related to allergic reactions would be :

  1. Medical History form submitted to the doctor 
  2. EHR report created by the EMR team while the patient was being admitted
  3. Medical records with diagnosis history, prescriptions of drugs administered and prescribed for later usage
  4. Blood and other test reports for showing signs of abnormality
  5. Nurse notes on patients state in relation to treatment provided
  6. Discharge summary if present 
  7. If the patient has a family medical history and has submitted the same to the doctor, that is important as well.

These documents provide testimony to the fact that the physician has not followed the standard of care and is responsible for the hardships suffered by the patient and their family. 

Medical Summaries Importance

Medical summaries are reports curated by thoroughly examining the medical documents provided and arranging them in chronological order for relevance and easy reference. In this specific medical malpractice case, medical summaries can help you understand and explain the course of events during the treatment and the effect of drugs prescribed to the patient. 

Medical summary firms such as the Medsum also provide insight into the important sections of the medical records and prepare a medically sound argument in favor of the patient for negotiations. 

Contact us today for a quote and detailed proposal.