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What happens when medical records are not accurate?

Miami, FL |

When alledging medical malpractice lawyers ask for medical records. But say in the process of personally reviewing my medical records I find that doctor truncated about 70% of my complaints to fit his diagnosis. Then the allegation of misdiagnosis fails because the doctor didn't record the information that I gave him. And then I would say "well, I told the doctor..." and then the doctor's defense would say "but it's not in the medical records." But I told him or her. What can I do about this situation?

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Attorney answers 4


Unfortunately there is little you can do at this stage. Welcome to the world of modern medicine where you do not know what id in your medical records until it is too late. This happens all too often, and the end result is exactly as you stated, it’s your word against the doctors.

DISCLAIMER: David J. McCormick is licensed to practice law in the State of Wisconsin and this answer is being provided for informational purposes only because the laws of your jurisdiction may differ. This answer based on general legal principles and is not intended for the purpose of providing specific legal advice or opinions. Under no circumstances does this answer constitute the establishment of an attorney-client relationship.


I somewhat disagree with Mr. McCormick. I deal with this situation frequently. Not only will doctors not record all of your symptoms, sometimes they will actually change or re-write their records. 99% of the time, the failure to chart all symptoms or mischart symptoms is not intentional or mischievous.

Imagine if you went to your PCP and told him you had a stubbed toe and your eye hurt and that he/she focused on your fractured toe. The fact that you had pain in an eye may not get charted but it may be that you have a vision problem which caused you not to see the chair which you hit with your toe. This happens all of the time.

Cases are not won or lost on one document. Even a physician who alters records can be stung by the truth. See an attorney who specializes in medical negligence litigation with your full history and with whatever records you do have to get an opinion. The fact that the physician did not chart something is not the end of the claim IF there was negligence on the doctor's part. Only a complete review can get to the bottom of this.

This is not intended as specific legal advice to you or about your case. The only way to provide that is for you to have a conference with an attorney so they can ask you questions about your claim, read records and learn far more than is contained in your note. No attorney-client privilege is established by this response.

David J. McCormick

David J. McCormick


I agree that some doctors will change wholly inaccurate notes, but it is difficult to do months/years later. Further, if the doctor’s office has a hint of a possible med. mal. case then they never will cooperate with your request for changes. I always advise clients to write everything down, make copies, and then bring in the documents to the doctor’s appointment. Given how busy most offices are these days, many doctors will just put note right into your chart and you could be protected from this very situation.


A swearing contest between a doctor and a patient is a tough one for the patient to win, but sometimes patients do win such cases. There may well be other evidence out there to corrobate your version. A good medical malpractice lawyer will take cases sometimes where the doctor just left stuff out of the record that can be proven to be true. Sometimes that even makes it a better case. So, don't be discouraged.

Any opinions stated in response to Avvo questions are based upon the facts stated in the question. Responses to Avvo questions are for general information purposes only, and should not be construed or relied upon as legal advice.


It is easier to overcome a lack of documentation, such as failure to records all of your complaints & symptoms, than it is to overcome erroneous documentation, where it becomes more of a "he said, she said". The problem is that often the expert for the plaintiff will only base opinions on what IS recorded, to avoid credibility issues. However, if you get past that, the jury will consider the patient's credibility in testifying about additional information that the doctor or doctor's staff failed to record. If you can find an expert to offer opinions on the standard of care, based on what is in the records, you should be able to proceed.

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