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FIXING THE RECORD AFTER THE FACT:
DON’T EVEN BE TEMPTED!
by Catherine Miller, RN, JD
CAP Risk Management
Alteration of the Medical Record is Always a Bad Idea!
A reference to "medical record alteration" conjures up images of obfuscation or deliberate falsehood, such as rewritten medical records or abricated accounts of care. In truth, however, alteration need not involve a physician’s intent to deceive. Actually, physician intent plays no part in determining if a record has been "altered." Many well-meaning physicians learn the hard way that the simple act of making an inappropriate modification to the medical record may be enough to raise suspicions of alteration. These actions may jeopardize one’s credibility and thereby imperil both legal defenses and professional liability coverage.
How It Happens
As evidence at trial, the written record plays a critical role in answering questions relating to the standard of care. Often, the physician-defendant is legitimately concerned about both the quality and accuracy of medical record documentation. In reviewing the record, the physician probably will discover at least some element of care that could have been better documented. He might find that: (a) documentation is misleading or unclear, (b) important information was left out, or (c) a particular entry would benefit from elaboration. Whatever the case, the physician may be tempted to "set the record straight" by changing the original entry. In the words of a physician whose MPT coverage was in peril for yielding to this temptation: "I only wrote what I wish I’d written the first time."
Altering the medical record is a sure way to lose credibility.
It Will Destroy Your Credibility and Your Defense
Although wanting to set the record straight is readily understandable, altering the medical record is a sure way to lose credibility in front of jurors or arbitrators. At trial, the patient’s attorney will take every opportunity to discredit the physician. Pointing to an alteration of the
record could persuade jurors and arbitrators that the physician is "untrust-worthy" and "dishonest." Once the physician’s credibility is irreparably harmed by proof of alteration, little else will be believed. With one’s defense so severely compromised, the physician and his attorney will be faced with choosing between two undesirable options: settling the case or taking the risk of losing at trial.
It Will Be Discovered
Often, a physician will be tempted to augment the medical record after receiving first notice of a lawsuit. But, that same physician may not realize that the patient’s attorney subpoenaed a complete copy of the medical record, months earlier. Any discrepancy between the original and the copy will, by itself, establish that the record was altered. If suspicion warrants further investigation, the alteration may be discovered through the sophisticated methods utilized by document examiners. In addition to handwriting analysis, these professionals are able to analyze ink to determine: (a) the timing of an entry, (b) whether the same writing instrument was used, and (c) if pages were removed from the medical record.
It is Excluded from Coverage Under the CAP Trust Agreement
Importantly, all members need to understand that, under the MPT trust agreement, alteration need not be committed with the intent to defraud. Any inappropriate modification of the medical record may be enough to bring coverage into question.
The Do’s and Don’ts of Modifying the Medical Record For Physicians and Staff
With coverage and credibility at stake, it is important that all individuals in your practice who enter information in the medical record understand the correct way of modifying the medical record. The following examples are offered to clarify these situations. We encourage you to share this information with staff and include it in the orientation of any new staff member.
• If I Make an Error While Charting, How Do I Correct the Information?
The correct way to modify an entry is to draw a single line through the original incorrect entry while leaving it legible. Write "error" above the original entry and initial it. Using white out or crossing out information is inappropriate and suggests that the original information was in some way damaging and needed to be "coveredup."
• If I Forget to Chart Information, or am Delayed in Charting, How do I Add Information Later?
Late entries must include the date on which the late entry is actually written and should be labeled as "Late Entry." If the late entry is an
addition to a previous note, then it should specifically reference the note by date: "addendum to note from 10/11/05."
• What If I Forget to Document Information That Might Be Important to My Defense?
Even if you believe that certain information will be crucial to your defense, resist making changes to the record until you contact the
CAP HOTLINE (800-252-0555)
or your appointed claims representative or attorney. Entries written in anticipation of litigation often do more harm than good by appearing desperate and self-serving. Be assured that you will have the opportunity to tell your version of events. For now, defer to your attorney and claims representative.
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