Record keeping changes could mask hospital mistakes

Record keeping is an important aspect of a medical malpractice case. Essentially, if a hospital has bad record keeping practices, chances are that it may be easier to prove that reasonable steps were not taken to ensure the patient’s safety, or that established procedures were not followed that led to the patient being harmed.

Indeed, some hospitals have exceptional record keeping practices. However, a new reporting protocol may mask some hospitals’ shortcomings. According to a recent Claims Journal report, some diagnoses to be reported under ICD-9 reporting codes may not translate to ICD-10.

For instance, an issue reported under ICD-9 may have several interpretations under ICD-10. Basically, accurate reporting under ICD-10 may make a hospital look safer than it really is. At the same time, other hospitals may seem less safe because of the different (and new) categories generated under the system.

With thousands of hospitals, coders and doctors, there does not appear to be a simple solution regarding a happy medium when it comes to recording. Moreover, it does not appear that hospitals are deliberately trying to game the system and improve upon their rankings when no reward is merited. After all, a number of hospital ranking sites and publications use these numbers. However, it does put into prospective the importance of accurate reporting and its role in litigating medical malpractice cases.

It remains to be seen whether there will be changes in how hospital codes are used. If you have questions about how these codes and terms are viewed, an experienced medical malpractice attorney can help.