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Medical negligence claims: the importance of clinical records

One of the first steps taken in investigating any medical negligence claim is to obtain a copy of the clinical records from the doctor and/or hospital against whom a claim is contemplated.

This is because these records form the foundation of most medical negligence claims.

Clinical records are often extremely helpful in outlining the injured person’s complaint and symptoms at the time they presented to the medical professional, as well as the change in those symptoms over time. Clinical records may also reveal what, if any, investigations were undertaken, test results given, diagnoses made and/or treatment advised.

An individual’s clinical records may provide more detail of aspects already remembered by them, or bring to light things that have been forgotten, or that they never knew.

Unfortunately, however, clinical records do not always contain the depth of information that they should. Sometimes there is very little detail recorded, if any at all, of say a consultation with your general practitioner or treating specialist.

A medical practitioner is under an obligation to make adequate records, and a failure to do so may itself form a particular of that practitioner’s negligence. However, this failure often puts individuals with a medical negligence complaint at a disadvantage.

This is because greater reliance has to then be placed on their memory, something which we all know is imperfect and can fade over time.

An individual’s memory will likely be challenged and tested by the defendant, and weighed against any contemporaneous record of the relevant facts and circumstances.

Therefore, it can be helpful to keep a personal record, which includes relevant dates, events, symptoms, advice and the like; as the closer the record is made to the relevant events, the more detailed and reliable it tends to be.

If you or one of your loved ones has been injured due to the medical negligence of a doctor, you may be entitled to compensation. You can contact Stacks Goudkamp on 1800 45 8142 or by making an online enquiry, to obtain friendly advice about your circumstances from one of our compensation experts.

Written by Laura Green.

Laura Green is a personal injury solicitor in Julie Mahony’s Practice Group. Laura works with Julie in a variety of personal injury claims, but has a special interest in representing plaintiffs in medical negligence claims.

2017-06-22T10:48:43+00:00 July 25th, 2016|