Texas Family Physician Volume 52 No.2

Alteration of medical records can make it impossible to defend a malpractice case. Consider the 1998 Alabama “medical malpractice case in which a patient died from lack of oxygen during surgery. At trial, an anesthetist testified that the critical period of oxygen deprivation was only about three minutes; however, evidence was presented that the decedent’s medical records had been altered, and a jury awarded her family $22.5 million.”1

TMLT is seeing an alarming increase in the number of cases involving alteration of records. Most physicians acknowledge that it is unacceptable to alter medical records. Nevertheless, there have been several situations where a physician caught in a dilemma yielded to panic and destroyed or changed a medical record entry, hoping that it would not be noticed. Not only was it noticed, but it fatally damaged an otherwise defensible case.

High technology has entered the arena of forensic record analysis. If a record is changed 20 minutes after it has been written, in the same handwriting and using the same pen, this can now be detected through Mylar transfer and other new analysis techniques. No secret will bear today’s technology. A change will surely be detected. Looking for alteration of records is often a routine procedure for plaintiffs’ attorneys. Commonly, a patient may seek the services of an attorney to help make a decision about filing a claim. The attorney instructs the patient to request records from the physician without mentioning the potential claim, and to deliver the records to the attorney for review. If the attorney believes that the case has sufficient merit to proceed, he or she requests a second set of records directly from the physician. A quick side-by-side scan of the two sets of records is all that is needed for the attorney to detect possible alteration of records. If an alteration has been made, it will surely be noticed.

Intentionally evasive alteration of records is not common. The increase in altered records cases being noted by the TMLT Claim Department may be due, in part, to additions and comments made by well-meaning physicians who are attempting to clarify or elaborate on previous notes. Anything added to a previous note is properly a late entry, regardless of whether or not the note was signed by the physician. This type of alteration— late entries written as part of a previous note—has been observed repeatedly by TMLT risk managers in the course of risk management practice reviews.

A late entry should bear the date on which it is written, and it should say, “LATE ENTRY.” The relationship to a previous note should be explained, e.g., “addendum to note of 2/26/99” or “see 2/26/99 note.” Also the reason for the late entry should be explained. Why wasn’t this information in the previous note? A late entry should appear in its normal chronological position in the chart, not squeezed into space near the previous note to which it relates.

What about the not-so-late entries? TMLT risk managers are often asked, “How late is late enough to be a late entry?” Once a note is finished, anything else is a late entry.

When in doubt, a late entry, clearly identified and properly referenced to the original note, is always preferable to adding anything to an existing note.

TMLT risk managers have also observed a bizarre form of shorthand being employed by some physicians which results in alteration of the record. A physician may write an order, e.g., “Tell her to stop taking (drug),” and then, after talking to the patient, changes it to “I Tell her to stop taking (drug).” In this example, a new note should have been written to document the phone call. Having to write a few more words is a minor effort, especially considering the risk of allegation of altered records.

Blank lines or large blank spaces in the medical record may constitute an invitation to make changes or additions to a note. It is wise to protect your medical documentation from such alteration by not leaving blank lines or by marking through spaces in a manner that prevents alteration.

Source

1. Medical Malpractice Law & Strategy, Vol. 16, No. 3, Leader Publications, January, 1999