Falsifying Medical Records

Evidence of falsifying medical records can be a lynchpin for a medical malpractice case. Medical records are legal documentation of a person's medical care. It is reported that one of the cases with the highest payout in history resulted in $74.5 million from negligence and falsified medical records. Throughout the course of someone’s medical treatment or hospital stay, there are many individuals who contribute to medical records, including physicians, nurses and ancillary services such as physical therapy or speech therapy. These medical records are further handled by non-medical staff, such as billing and coding or administration. With all the hands that touch a patient’s medical record, it is important to identify any discrepancies that might indicate altering of the record.

Medical records may be modified for a number of reasons that are not intentionally meant to be or appear to be falsifying information. For example, clerical errors can cause wrong information to be entered into a patient’s medical record that needs to be modified, such as a nurse charting on an incorrect patient. These entries are often redacted from the record. A provider may choose to modify a document to add or change information to improve accuracy of the patient’s course of care. These often appear as modifications or addendums. Care must be taken when a chart is updated to ensure that when these changes are made, it does not add suspicion of record falsification in the instance of a malpractice case.

In some states, the changing of medical records can be an illegal action in its own right. Obviously, when medical records are intentionally modified to alter accounts of concerning events, this indicates that errors were in fact made. In healthcare, there are sometimes unfortunate outcomes to interventions, procedures or illness, despite even the best care. But when records are changed, a doubt of the causation to the poor outcomes may arise that can be used in court. In new electronic medical records, it is often easy to see modifications as there is a draft of all cancelled and changed documents. There is also a log of who made the change and when it was made. Some changes that can indicate intentional tampering are changes made by someone other than the original author, changes made a significant time following the incident in question, or changes made after a lawsuit was filed. When reviewing medical records, a nurse needs to pay attention to any modifications made to medical documents.

A legal nurse also needs to identify any apparent omissions from a medical record that might have been intentionally removed from a records submission. An omission of documentation for a specific incident can be just as indicative of medical record falsification as a change in documentation. This entry may have been intentionally removed from a medical record as an attempt to remove potentially inditing information. It is also important to note discrepancies in time entries, such as records that appear out of order or after the fact that may be falsified information to attempt to cover wrongdoing.

Many cases of potential medical malpractice are strengthened or solidified if there is evidence of tampering with a medical record. This can be an important key for a prosecution. Potential falsification of medical records is also critical for a defense lawyer to know, and whether it can be used against their client. Falsification of medical records, omission of medical records, or modification of medical records has been key to winning some of the cases with the highest payouts in history.

To speak with an experienced team member, contact LEGAL NURSE CONSULTANTS USA, LLC online or call us at 877-211-7562 for a free consultation. You may also leave your contact information and a summary of your potential case, and a team member will get back to you promptly after review.