Accurate and complete medical records are essential for quality of care, compliance with payment requirements and for use in legal proceedings. There is a tremendous amount of pressure on providers to timely document all facts surrounding their patient interactions. Unfortunately, at times, the medical record is unclear, incomplete or inaccurate. A provider may not realize the inadequacies in his/her documentation until faced with a patient complaint, a professional misconduct investigation or lawsuit. At such times there can be a strong temptation to add to the medical record to “clarify” what actually occurred, remove potentially damaging information or even create a completely new record.
However, alteration of a medical record can carry serious consequences for the practitioner. For example, proof that a medical record has been intentionally altered can result in the cancellation or non-renewal of an insured’s professional liability insurance policy. In addition, if a provider is sued for medical malpractice, an improper alteration of the patient’s medical record may very well destroy his or her ability to defend the case. This is true even if the medical care in question was entirely appropriate.
The medical record is one of the most essential tools in the defense arsenal. It documents the patient’s history, the provider’s thought process, the basis for the diagnosis and treatment, and communications with the patient. Often, the patient’s version of events conflicts with what the provider has documented and, in such cases, the contemporaneous documentation is likely to be more persuasive. Documentation of the facts supporting the provider’s reasonable judgment will offer protection in showing that the standard of care was followed. Moreover, the record will show if the patient cancelled or failed to keep appointments, or if he/she was non-compliant in following treatment recommendations.
Medical records which are undated, illegible, incomplete or clearly erroneous can be used by a plaintiff to cast doubt upon the quality of care the patient received from the provider. Proof of medical record alteration, without good cause and proper authentication, has serious consequences in malpractice litigation. Altering a medical record implies tampering with the evidence. Such proof will destroy the defendant’s credibility before a jury and will leave the strong impression that he or she is trying to hide the truth. Evidence indicating that a record has been altered can force the settlement of an otherwise defensible case.
Occasionally, upon review, a provider may discover that certain entries were not properly documented and need to be corrected after rendering the service. From time to time it may be necessary to correct a mistake or enter more accurate information. Any changes to the original documentation must be legitimate and must be accomplished in an appropriate manner. All changes must be clearly labeled as such so that there can be no allegation of fraudulent conduct or an intentional cover up. Organizations should have clearly defined guidelines regarding when and how changes may be made in order to protect against perilous consequences.
This blog post is an excerpt from the cover story of MLMIC’s Fall 2016 Dateline. The full Dateline article includes general legal guidelines for maintaining medical records and suggestions for appropriate corrections to paper and electronic records. It also describes criminal penalties for alteration of records, professional misconduct violations and the processes that can bring altered records to light. In addition, this cover story is accompanied by a case study in which altered medical records led to a settlement. You can access Dateline here.