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. Regardless whether you begin with personal injury or defensible medical malpractice, the presence of altered records calls medical practice into question. Attorneys and paralegals can rely on legal nurse consultants’ experience and discernment to ferret out tampering and get to the heart of a medical case. This post begins a series on problematic medical records, and how to discern the source and the severity of their particular issues.
Medical records are not tamper-proof. Though healthcare professionals can feel like they’re operating in a closed system, medical records are widely accessible and often reviewed. A variety of caregivers enter data into medical charts: Nursing assistants enter vital signs; physicians add notes from patient assessments; and consultants record their own expert conclusions. In most cases, each of these professionals can see and access the complete record, regardless the extent of their training, or the level of their decision-making clearance. In today’s electronic systems, each of these providers owns a unique login, making it easier to identify the author of each piece of data. But keep in mind how easy it is for one person to remain logged in and another to add to that patient record under another caregiver’s login.
Beyond the healthcare site, a variety of outside organizations can access medical records. Federal and state agencies provide oversight to local medical providers; they may analyze records as a matter of routine, or especially when investigating a complaint. Medicare, Medicaid and private insurers all review medical records to determine eligibility for treatment and services. Each of these outside professionals is, to some degree, trained to recognize fraudulent medical records.

Attorneys and paralegals need to know the ins and outs of the complex medical system, so they can gauge the authenticity of the medical records they rely on for their cases. Legal nurse consultants provide a vital partner in navigating the medical realm and building winning cases.

In the next few posts, we will be covering the subject of medical record tampering in more detail, including:

  • Differentiating Between Substandard vs. Fraudulent Records
  • Signs of Possible Records Tampering
  • Legal Implications of Tampering
  • How Tampering Occurs
  • Photos/Examples of Fraudulent Records