Warfarin has a narrow therapeutic window and side effects include bleeding causing e.g. hospital admission and death. Monitoring of treatment and review of indication are mandatory. We report a case of more than four years of warfarin treatment without indication. Treatment was not discontinued due to inadequate medical record keeping and communication among healthcare providers. Medical-record keeping should follow guidelines from the National Board of Health. In addition, clearly stated treatment duration and indication may prevent unwarranted or premature termination of treatment.