May 28, 2013

The Challenge of Altered Medical Records in Malpractice Cases

by Levin & Perconti

With all of the discussion of “rampant” lawsuits and doctor’s fear of malpractice laws, one might get the impression that winning a case for negligence is easy. The opposite is true. In all civil lawsuits, the benefit of the doubt goes to the defendants, as the plaintiff (injured patient/family) is required to prove each element of the claim.

Even in cases where negligence occurred, securing enough proof for the mistakes can be hard. For one thing, the defendant usually has access to all of the necessary material to show what happened. That material takes many forms, from patient medical records to the recollections of those who provided the care. The defendants are required to provide access to the necessary information as part of the “discovery” process of litigation. But on many occasions those parties are less than forthcoming, using every available tool to delay providing the information to trying to withhold important details altogether.

In the worst cases, the very medical records which are critical to the case are altered, painting a false picture of the care that was provided to the patient in the case. Considering that the documents are in the possession of the defendant and can be decisive in a case, the unlawful “doctoring” of those records is far more common than one might expect. Unfortunately, it has become critical for medical malpractice lawyers to familiarize themselves with the signs that these records were altered.

Detecting False Records
The book Medical Legal Aspects of Medical Records, provides a range of tips for practitioners when it comes to spotting these issues. The list includes both signs that there may be problems with the documents as well as practical strategies for dealing with the situation to improve the chance that the truth eventually comes to light.

Many of the suggest relate to comparisons of different types of records. If there is inconsistency, then it might be a red flag of some problems. Nurses’ notes, for one thing, should be compared to other patient records for possible problems.

Similarly, billing records should be compared with documented care in a patient file. If a service or visit was billed but not documented, then it may be a sign that some files or information are missing in the record. For example, a doctor may want to deny that a patient visited on a certain day in a failure to diagnose case. The doctor may have missed clear signs of a medical problem and wish to pretend that he never even saw the patient by removing records of the visit. Yet, if the facility billed insurance providers for the service, then its an indication that something is wrong with the paperwork.

Along the same lines, employee schedules can be checked to ensure the actual employee who is said to have performed some service was even on the clock at the time. Surprisingly, many cases of altered medical records are done rather sloppily, with those faking the report failing to ensure their alterations even fit with who was working.

There are many other ways that lawyers familiar with these cases can explore if there are suspicions of altered medical records. The risk of this sort of conduct is one reason why it is important to have the help of a legal team that has deep experience on these matters which can be put to use for you.

See Other Posts:

Nursing Levels - Cutting Back Hurts Patients

Refocusing the Debate: Litigation Improves Patients Safety