Your analysis of medical records shows that a provider tampered with medical records. You have a healthcare provider or possibly a documents examiner confirm your suspicions. Here is what can happen next.
Legal cases often arise because of conflict over medical care. Whether representing plaintiff or defendant, you need thorough and accurate patient records to construct your case and serve your client. For legal professionals handling medical documentation, it's imperative to know what tampering looks like and how it happens.
When you uncover inaccuracies in medical data, they may well be a result of unintentional error, but sometimes the alterations will look more intentional. In my last blog post, I homed in on these suspicious inaccuracies; this week, I'll shine a spotlight on some typical tampering incidents.
Think of the accuracy of medical records as a continuum: At one end are accurate records; at the other end are modified records. Patient data becomes suspicious when there are detailed supplements, including information that might even be accurate and valid. Watch for detailed notes about treatment, patient discussion and post-treatment counsel. This is particularly important when there has been a negative outcome.
Risk managers call these addenda “panic notes;” they're almost always written because the healthcare provider has realized that the patient experienced a serious complication; the provider may even have discovered that the patient has consulted an attorney.
There are a number of reasons why medical records can be substandard. Often the pressure to conclude care (and shift attention to the next patient) takes priority over charting. A healthcare professional may be interrupted, and may not ever be able to get back to completing a medical record. This isn't a deliberate action; rather it's an accidental event that occurs under production pressure. “Production pressure” refers to the stressful obligation, and accompanying difficulty, to deliver healthcare in a timely manner. Unfortunately, incomplete notes can contribute to negative clinical outcomes, because important information may be missing from the medical record.
Medical records are surprisingly vulnerable to tampering. In medical cases, discovering fraudulent records alters the very nature of a case. It’s imperative that legal professionals are equipped to identify fraudulent medical charts.
This post wraps up an ongoing series on managing and organizing medical records; here we provide a review of some of the topics discussed in the series, plus our Top 10 Hints for Medical Record Management.
Attorneys are often overwhelmed by the volume of material they receive when a medical provider forwards electronic medical records. Even though electronic record systems are intended to produce less paper, they actually contain more documents than a typical paper chart.
Physicians’ office records have predictable sections. Within your legal practice, it’s best to develop a consistent order for medical records so that all who access the records know where to find necessary data. Color-coded tabs can be a helpful addition, as these records tend to be extensive.