Records Not Kept with the Patient’s Chart
Very often, hospitals maintain records dealing with patient care that are not part of the patient’s chart. The ‘Narcotic Administration Record’ discussed in the recent decision of Hein v. Community Medical Center [8-9-06] is a good example. There, an issue arose as to whether one of the patient’s doctors administered excessive amounts of Fentanyl to a patient, contributing to her death. The doctor denied it, and, at trial produced a record maintained by the pharmacy department entitled a ‘Narcotic Administration Record’ indicating Fentanyl had not been signed out to, or, dispensed by the doctor. The pharmacy apparently kept records on the disbursement of controlled dangerous substances, like narcotics. I have also found, in my own cases, that pharmacy departments often keep separate records on when other medications are dispersed as well. Thus, when an issue arises concerning what medication had been given to a patient, separate requests should also be made to the pharmacy department for this information.
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