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"Copy and Paste" Documentation Harms Defense

When Sarah Haack suffered a stroke and made a malpractice claim against her chiropractor, Dr. Peterson's records didn't match what he told the jury. What went wrong?

Dr. Joseph Peterson had an established patient, Sarah Haack, who frequently complained of right neck pain and headaches. Dr. Peterson elected to treat Sarah with cervical adjustments and also used the diversified lateral break technique. Dr. Peterson suggested that this was Sarah’s baseline, and she did experience some relief after treatment. However, Dr. Peterson failed to document the history of headaches, only neck pain.

One week, Sarah was treated on a Monday, then returned two days later, reporting neck pain and headaches. She also reported experiencing nausea, vomiting, and dizziness the day prior. It was argued by her attorney that at this point, Dr. Peterson needed to make a referral to the emergency room, because even if neck pain and headaches were baseline and nonspecific, the addition of nausea, vomiting, and dizziness were new symptoms more indicative of an ongoing vascular injury.

Instead of making a referral, Dr. Peterson testified that he modified his treatment plan for that day, foregoing the performance of a cervical neck manipulation and instead only providing massage and light manual therapy. The plaintiff testified this was not true; she had received the same treatment she always had, which included cervical manipulation.

In the month prior to these events, Dr. Peterson had transitioned from paper to electronic medical records. He was having issues with the technology, so his notes for the last 15 visits or so were all identical, appearing to just be copied and pasted every day. Due to this, on the day he testified that he did not adjust the patient’s neck, his records stated that he did and that she responded well. Despite extensive preparations for testifying, Dr. Peterson was not able to articulate a believable explanation for these charting errors to the jury.

Sarah Haack also testified that after the alleged adjustment which Dr. Peterson denied performing, she immediately felt as if she was going to get sick, was dizzy, and had to use the wall to steady herself as she stumbled to the bathroom. Dr. Peterson denied this occurred but did concede the patient appeared nauseous and was in the bathroom following the treatment.

Both Sarah and Dr. Peterson testified that she remained in the office for about an hour while she was monitored. Once the symptoms subsided, Dr. Peterson allowed her to return home. He told her that if the symptoms returned, she should go to the emergency room. Sarah’s attorney argued that this was yet another opportunity where Dr. Peterson should have made a referral to the emergency room, regardless of whether the symptoms subsided. It was argued that had the referral been made, Sarah could have received the anticoagulation treatment she needed, which would have prevented what transpired in the following days.

Later that week, Sarah woke up in the morning to discover that she had developed blindness, which required hospitalization. She was diagnosed with a stroke due to a suspected vertebral artery dissection in the neck but was determined to be outside the window for tPA. As is typical of charting in hospitalizations like this, the care providers often referenced the chiropractic treatment as the potential cause of the suspected dissection.

However, Dr. Peterson had qualified expert witnesses who identified the source of the stroke and the timing of its onset. The defense had a vascular neurosurgeon who was able to identify a congenital abnormality in the vertebral artery, a fenestration, which was where the possible dissection had been identified by the patient’s radiologists and neurologists during her hospitalization. This abnormality causes increased turbulence in the blood and makes the patient more susceptible to clotting in that area. There was also no evidence on imaging of an actual dissection, it was only suspected given Sarah’s history of chiropractic adjustments. As an aside, this is a common misconception within the medical community based on outdated literature. The most up-to-date studies show there is no evidence of a causal relationship, and further, chiropractic adjustments do not exert sufficient force to compromise the arteries in the neck.

Sarah also had other risk factors for abnormal clotting and stroke, including two genetic clotting abnormalities, and a patent foramen ovale (PFO) in her heart that would allow clots to pass from the lower extremities to the left side of the heart and directly to the brain.

Despite these explanations, it was believed the jury could not get over Dr. Peterson’s credibility issues, given that his own records contradicted what he said occurred in his office. With his credibility damaged, Sarah’s attorney characterized Dr. Peterson as an overzealous care provider who should have made an immediate referral to the emergency room once the patient developed nausea and vomiting at home. He certainly should have made a referral once the symptoms presented in-office later that week, as this coupled with her neck pain and headaches could be evidence of a vascular injury requiring medical treatment.

The damage to Dr. Peterson’s credibility was done. His poor record keeping, coupled with his poor explanation for the care and treatment he rendered in light of his records that contradicted him, resulted in a verdict against him in an amount over $600,000.

What Can We Learn?

Despite having a viable defense, the chiropractor was found liable, likely due to pitfalls along the way that impaired his credibility and skewed the way the jury viewed his testimony.

Keep detailed records. Poor recordkeeping handicapped Dr. Peterson’s credibility with the jury. Although he tried to explain that he was not concerned with the symptoms because they were either baseline for this patient or were not present at all, his records did not reflect this. The focal point of the case became the recordkeeping and the implication that the chiropractor was trying to rewrite history because his records told a different story.

Refer sooner rather than later. It was argued that there were signs and symptoms of vascular injury displayed by the patient which required referral to the hospital for work-up and anticoagulation therapy. Depending on the clinical presentation, there may be instances where, out of an abundance of caution, changes in condition warrant a suggestion to the patient to seek further treatment.


About the Author

Austin C. Monroe is a trial attorney handling cases in Illinois. These cases have included physician and other healthcare malpractice, trucking and automobile liability, construction and premise liability, and other claims for catastrophic injury. Mr. Monroe has been heavily involved in complex cases, from the filing of suit through trial.

At Penn State Law, Mr. Monroe was a member of the school’s national trial team, as well as an editor, and later executive board member, of their Environmental Law Review.

Mr. Monroe has been named an “Emerging Lawyer” by Leading Lawyers, Law Bulletin Media, awarded to less than 2% of lawyers licensed to practice in Illinois. He has also been named a “Rising Star” by Super Lawyers, Thomas Reuters, an honor given to no more than 2.5% of lawyers in the state.

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