Tampering with Medical Records Can Make a Medical Malpractice Case Indefensible MOS Medical Record Reviews
Attorneys handling medical litigation need to be wary of a sinister problem associated with medical records – signs of tampering. What exactly is tampering? It may range from additions made to the patient’s health record at a later date, adding inaccurate information, deleting important facts, predating the record, rewriting them, destroying them and adding to another provider’s notes. Only professionals proficient in the medical chart review process can easily identify the signs of alteration. Advanced technology available at present can be used to spot additions, deletions and modifications.
Why Providers Resort to Tampering
Tampering is usually done to cover up some mistake or shortcomings in providing care to the patient in a timely manner and such other reasons. A hospital in Adelaide recently faced such a serious issue when four of their staff members deleted a radiologist’s comments about hospital management from a patient’s medical record. The comments were those associated with the ordering of tests and delays in reporting those test results. The doctor whose comments were removed expressed deep concern over the issue. The four miscreants ranging from middle management and higher have been counseled in this regard and have admitted that they made a mistake.
In the United States, tampering with records is recognized as a separate tort action by several states. Expert medical reviewers looking for signs of tampering carefully evaluate whether any documentation is missing. Typically, a set of indexes are used to
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find out whether all the components of the medical chart are present. This helps to identify entire sections of the chart that are missing. When reviewing medical records, it is important to be familiar with the typical components of the patient chart and the way each facility makes the chart. In addition, the reviewer must know what documents need to be examined and have expertise in spotting all kinds of discrepancies. Lawyers and their office staff can save time and effort by roping in reliable medical review services.
What Medical Record Review Professionals Look for
Huge gaps in documentation
Late entries
Broken chart entries
Additions to the notes
Lack of clarity in injury documentation
Existence of handwritten and typed notes
Deletions of entries
Changes in the style of note writing
Entries that are out of chronological order
Altering medical records can prove very costly for healthcare professionals facing a malpractice lawsuit. Accurate, comprehensive medical documentation is vital from the point of view of patient care as well as defense in the face of such a lawsuit.
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Healthcare providers may occasionally need to make genuine changes in the medical chart, in which case it must be done honestly and appropriately.
Any correction made has to be recorded with the correct date and time. Additional notes can be provided regarding why the entry has been added at a later stage.
If some detail that has been left out is to be added at a later date, truthfully date the annotation specifying that it has been added after the fact. It’d be ideal if the reason why it was omitted in the first place is added.
Any addition made must be obvious and legible so that there is no scope for ambiguity.
Tampering with medical records is not acceptable because it is a criminal offense. Documents that are altered after they have been subpoenaed will fall under minute scrutiny and jeopardize a malpractice defense. Other eventualities include cancelation of the practitioner’s insurance coverage, criminal charges for perjury and fraud, and loss of license. Clear signs of tampering that emerge via a medical chart review make a case practically indefensible for the physician.
www.mosmedicalrecordreview.com
800-670-2809