What’s in a Name?

I recently received computer generated medical records printed on paper for a forensic examination from two different providers. None of the sheets included the patient’s name or the provider’s signature except the psychotherapist who did sign a brief handwritten note on one page apologizing for the fact that the entry in one field repeated for each session note. She apparently overlooked several similar repetitions in other fields.

I can easily imagine that a state medical board might take a dim view of unidentified medical records, but the consequences could pale in comparison to what might happen if you tried to use such records to defend yourself in a malpractice case. A plaintiff’s attorney could (and should) have a field day attacking the credibility of either unidentified or unsigned records.

Of course the problem surfaces in the printing. Viewed in their native environment on a computer screen the name of the patient will undoubtedly display. The digital signature should exist somewhere with all the other “metadata,” even if you cannot see it on the screen.

I look forward to the day when I can access a patient’s medical records in a forensic case on a computer screen rather than thumbing through a stack of paper or even scrolling through a .pdf file.

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