You are served with legal documents stating that a former patient is suing you for malpractice. Or, perhaps you receive a letter from the patient's attorney advising you of a claim against you. Should you attempt to "clean up the records"?
by Lori Holt in Documentation on Tuesday, January 28, 2020
Being sued is startling or perhaps even frightening, and many doctors will want to correct any inadequate or inaccurate documentation in the patient's chart. Big mistake.
No matter how innocent the intention, any change, if not done properly, can be viewed as a self-serving attempt to cover up a misdeed.
With electronic records, a forensic computer analyst may review the procedures for making computer entries to determine when the entries were made—during or after the office visit.
The analyst can often detect any changes to the records, including any reformatting of and deletions to a patient's record.
Experts can point out variations in handwriting, chemical content of inks, types of pens or types of forms. The example at right shows how obvious detection can be. To the naked eye, the first blood pressure reading appears to be 120/80. However, infrared luminescence provided proof that a different writing instrument was used to change the entry, which was originally 170/90. The black ink of the altering pen glows white, showing where the original entry was changed.
Additionally, document examiners can scrutinize handwriting to determine who wrote the entry, and they can evaluate folds, creases, and staple and punch holes to determine if pages were inserted or removed or if the document sequence was altered.
More Ways Alterations Are Detected
Plaintiffs will try to determine if the records you provided during litigation are different from earlier records. They want to find out if you altered the records after the claim was made.
To do this, the plaintiff will often compare the records you supplied to providers or to patients during the course of treatment with those you supplied after being notified of litigation. The plaintiff’s attorney will look for new entries, pages missing from the first set of records and pages added to the first set of records.
The Penalty for Altering Records
Improperly changing clinical documents can invite a world of trouble, in addition to jeopardizing a malpractice defense. In some states, you could face criminal charges for fraud and perjury, or you could lose your license. Authorities/state boards may consider an alteration serious professional misconduct.
That's why it is essential to heed the advice of your defense team. They are here to guide you through the process and protect your interests in all respects.