Altered Records: How Proper Documentation Can Mitigate Risk & Bolster Defense

Timothy R. Bone, President, MedMal Direct Insurance Company // November 24, 2011

patient’s medical record in Spanish. A year later, the office manager received a record request from an attorney and learned that all records were supposed to be kept in English. After sitting down with a pen and copying all of the notes from Spanish to English, she then threw away the notes in Spanish. Even though the transition was innocently done, it created an unnecessary negative; and it appeared as if the physician has recreated the record for a malicious purpose. This case was settled.

Altered records continue to prompt significant monetary losses, even though risk managers have educated practice managers for decades on this vital issue. When it’s discovered that records have been altered, even if the alteration was unintentional, risk managers know there is simply little to no defense for the physician, said Timothy R. Bone, president of Florida-based MedMal Direct Insurance. “I have enough stories to fill an entire book on the subject of altered records,” said Bone, who has handled thousands of medical malpractice claims during his 35 years in the medical malpractice insurance and healthcare risk management industry. “It appears to be simple human nature, especially for the highly intelligent, to think it’s possible to alter or recreate an earlier created document so that the information in it supports the decisions made by that highly intelligent person. Though we’re very fortunate to have the finest physicians practicing the best clinical medicine in the world, we also live in one of the most litigious societies in the world; and physicians are both highly intelligent—and very human.”

It’s even easier to document alterations in an electronic format than it was “in the old days” with a paper record, Bone pointed out. “Every single keystroke or mouse click is recorded, dated and time-stamped in some backup database, which is being backed up by another backup database every 15 minutes,” he said. Especially with the advent of the electronic age, which makes data recording even easier, “old-fashioned principles still apply.” The methodology for the issue of altering records should involve risk management, clinical staff, and information technology staff. The solution is to eliminate the practice of “altering” as opposed to “correcting” records.

The review procedure involves:

  • Obtaining a sample of 50 medical records of recently discharged patients.
  • Appointing an ad hoc committee of a physician, a nurse, a medical records staff member, and an information technology staff member to review each medical record separately for progress notes, consultation reports, order sheets and, if applicable, operative reports. 
  • Checking for the presence or absence of entries that would appear to suggest an “altered” or “incorrectly amended” record. 
  • Tallying the total number of items reviewed and the total number of possible “alterations” for each member of this ad hoc committee; and then tallying the totals of the committee itself. 

Actions to be taken include:

  • Notifying the medical executive committee and the medical staff if all is in order. 
  • Devising a solution, implementing it, re-auditing the issue within a given time frame and reporting to the medical executive committee and the medical staff about both the activity and the outcome—if problems exist. 

“Throughout the years, the advice has remained the same: if you need to ‘correct’ a record, pull out a fresh piece of paper or the electronic equivalent, put today’s date on it, and then fully explain yourself,” said Bone. “Otherwise, you may end up in a situation similar to the following actual cases.”

  • A patient was being treated over many months by a primary care physician, but the patient absolutely refused to follow the physician’s orders to have blood work done. Unfortunately, this refusal wasn’t noted in the record. When the record request from the attorney was received, the physician went back through the record, adding statements about how the patient refused the recommended blood work. In hindsight, these statements appeared to be self-serving. This case was settled. 
  • At trial, a plaintiff’s attorney called to the witness stand an expert in the subject of ink used in pens. (Yes, such an expert actually exists!) The expert was able to show that the ink used in the medical record had not yet even been manufactured when the dates of treatment took place. This case was settled shortly after this expert’s testimony. 

“Though the process of taking the additional time to clearly communicate via the medical record takes some effort, it has shown, over time, to achieve the stated goal: mitigation of the risk that leads to medical malpractice lawsuits and enhancement of the defense of the case after the lawsuit has been filed,” said Bone. “It’s worth saying one more time: if you need to ‘correct’ a record, pull out a fresh piece of paper or the electronic equivalent, put today’s date on it, and then fully explain yourself.”