A medical doctor made a statement in a medical records that was speculative. How do we get the statement changed in the records

Asked over 1 year ago - West Hills, CA

My sister had a stroke. When she was brought in to the ER he was incoherent and could not speak. A nurse took it upon herself and claimed my sister had overdosed. One of the doctors treating her wrote in the medical records that he felt she was a drug abuser and an alcoholic, however the lab report indicated that she did not have any alcohol or the type of drugs that he had claimed she was using. My sister does not drink nor does she use drugs. She has diabetes and the doctor never asked our family about her previous medical conditions. The statement is reckless and damaging and unsubstantiated. Do we have cause for a malpractice suit to have the medical records changed?

Additional information

Thank you for all the replies. I do need to stress that the doctor only briefly spoke with my mother and they never went into detail about her past medical conditions, so when they started treating her, they never addressed those issues. I agree that we need is for the doctor to clarify his statement or address it further? What type of lawyer would we seek to help us have the medical records clarified or at least review the records for us and offer some advice on how to proceed? There is no law suit. We just want the medical records clarified as when we have sat down with different entities (who are not medical experts), they reference the remark by the doctor and we have to point out, "no" take a look at the lab report. Yet, they do not know how to interpret the findings.

Attorney answers (5)

  1. Paul Y. Lee

    Contributor Level 18

    5

    Lawyers agree

    Best Answer
    chosen by asker

    Answered . Statements in the medical records are not admissible evidence. They are hearsay. Don't get hung up on the statements in the medical records. Instead, have your attorney take deposition of the doctor and get the doctor to admit that the statements are in error or are without foundation. Such admission will be evidence. If there is no lawsuit pending, you still may be able to obtain an affidavit or declaration from the doctor. Good luck.

    This response is for information purpose only and does not constitute a legal advice. This response does not... more
  2. Elizabeth Taylor Herd

    Pro

    Contributor Level 19

    3

    Lawyers agree

    1

    Answered . I am sorry that this statement has impacted your family. However the testing puts that issue to rest completely. Doctors are required to develop a differential diagnosis which is speculative. They develop a list of potential causes for what they observe clinically. Then they eliminate the likely and most harmful causes through testing u til a diagnosis is reached.

  3. Martha Ann Knutson

    Contributor Level 11

    1

    Lawyer agrees

    1

    Answered . You sister has a right under federal and California law to ask for an amendment of her record. The hospital will have a process for considering her request - the medical records department is the best place to start. The hospital and the doctor that made the statements you disagree with do not need to agree to change them, but your sister at a minimum has the right to insert in her record a statement of what she disagrees with what's there. I'm including links below to the Medical Board of California's information about this and a hand out from the federal Office for Civil Rights.

    This response is intended to provide general information, but not legal advice. The response may be different if... more
  4. Josh P Tolin

    Contributor Level 19

    2

    Lawyers agree

    1

    Answered . No and No. First of all, your sister's medical records are private. Without a HIPAA release that she has to sign ,no one else sees them. From a damage perspective, no one other than a healthcare provider who needs records to treat her, or your sister, will see. Ms Herd is right. When your sister came in, and because of her stoke was incoherent, drugs, and/or a drug reaction would and could be part of their differential diagnosis. Obviously they diagnosed her correctly with a stroke, so the discharge diagnosis would be a stroke. Focus on helping your sister get better, you should not stress, worry, or bother suing over the medical records issue.

  5. David Ian Schoen

    Pro

    Contributor Level 20

    2

    Lawyers agree

    1

    Answered . Not a malpractice suit per se, but there are remedies that are best addressed by a health care attorney.

Can't find what you're looking for? Ask a Lawyer

Get free answers from experienced attorneys.

 

Ask now

26,766 answers this week

3,183 attorneys answering

Ask a Lawyer

Get answers from top-rated lawyers.

  • It's FREE
  • It's easy
  • It's anonymous

26,766 answers this week

3,183 attorneys answering