Visitor Question

Do I have a case after finger amputation and missing medical records?

Submitted By: Stephen (San Diego, California)

I went to the hospital with a finger laceration. I was given injections of lidocaine/epinephrine and bupivicane into my finger for pain relief. My finger was cleaned, put in a splint, dressed, and I was released.

Three days later, my finger was throbbing beyond belief, so I took off the dressing and splint. I noticed the tip of my finger was becoming necrotic and saw a distinct “ring” around my finger at the location of the injections.

I immediately returned to the ER. I was admitted to the hospital for four days and put on IV antibiotics.

After being discharged, my finger deteriorated more and more until a partial amputation of my finger was necessary. After the amputation surgery and while still in the hospital, I became aware that NONE of the injections I received were anywhere to be found on my medical records.

I feel it was the injections that were vasoconstrictors that lead to the necrosis and ultimate amputation. I have since gotten the physician to admit giving the injections but not until after the amputation. Now I need to prove it was the injections that caused the necrosis. Do I have a case? Thank you.

Disclaimer: Our response is not formal legal advice and does not create an attorney-client relationship. It is generic legal information based on the very limited information provided. Do not rely upon the information in our response, or anywhere else on this site, when deciding the proper course of a legal matter. Always get a personalized case review from a local attorney.

Answer

Dear Stephen,

As the plaintiff in a medical malpractice case you would have the burden of proving that the doctor fell below the standard of care in his or her treatment of you. The starting point in this establishing the doctor’s negligence is typically the medical records. You may still have a case, however, if the medical records are missing or incomplete.

It appears from your question that there are medical records related to your emergency room visit, but that those records failed to note that the injections you were given. This is a different issue than what you would face if your medical records were completely missing.

It is not unusual for doctors to unintentionally omit information from medical records, but it would be highly unusual if those records (and your medical bills) failed to include injections you were given.

There are several ways you can attempt to deal with this issue:

First, are there witnesses to your treatment? Were you accompanied by a family member or a friend who was with you when the injections were given and could testify that you did receive one or more injections? Also, was there a nurse involved in your care who might remember you receiving the injections?

Second, have you looked at your medical bills? Medications are typically billed on an individual basis and there may be an itemized charge for both the medications injected into your finger and a charge for the doctor administering the object injections.

Next, were you given a discharge summary that addresses the treatment you received and/or what you should do going forward? Check your records and see what you were provided when you left the hospital. You may be holding a reference to the injections.

Further, were the medical records kept electronically?  If so, it may be possible to go back into the computer files and determine if the records were altered after your treatment.

Finally, California Health and Safety Code § 123111 gives an adult patient:

“…the right to provide to the health care provider a written addendum with respect to any item or statement in his or her records that the patient believes to be incomplete or incorrect.”

By adding an addendum you can attempt to correct the omissions from your records. This addendum, however, will still pit your word against the doctor’s unless you have witnesses or other evidence that the injections were given.

Errors in medical records can present unique complications for patients who feel like they have been harmed by a doctor’s negligence. An experienced medical malpractice attorney can give you additional guidance on how best to proceed.

Learn more here: Tips for Medical Malpractice Claims

The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from a licensed attorney.

Find a local attorney to give you a free case review here, or call 888-972-0892.

Best of luck with your claim,

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