In legal cases involving medical care, quality patient records are of paramount importance. Your ability to construct excellent client representation relies on solid evidence, so any instance of tampering with patient data can be critical to your argument.

When you discover compromised records, it’s important to distinguish between substandard records and those that have been tampered with deliberately. In my last blog post, I began a series on medical record tampering. In this edition I will address various causes of substandard medical documentation. In the next post, I'll turn my focus toward suspicious inaccuracies in patient records.

Substandard vs Fraudulent Records
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. 

Similarly, medical records may be substandard because they were completed long after the events in question. A provider may dictate a history, physical, operative report, consult or discharge summary too long after the patient’s care. Late documentation is a red flag. Part of a detailed review of records involves examining the date of dictation or chart entry and noting significant discrepancies relative to the original date of service. Those dates become important when they are tardy. Hospital regulations typically require discharge summaries be completed within 30 days, not months later, as sometimes is the case, and certainly not after the patient has been discharged and later readmitted because of a complication. Hospital administrations may withhold or suspend the privileges of physicians who get behind in dictating their discharge summaries. Physicians are much more compliant when their faculty status and admitting privileges are tied to timely completion of required documentation.  

Sometimes Illegible, Sometimes Inaccurate
For legal professionals, deciphering illegible records can be a tremendous source of frustration. Unreadable handwriting is a huge problem in the clinical care of the patient. Malpractice insurance carriers say illegible handwriting can lead to extreme difficulty when defending lawsuits, even when the provider did nothing wrong. Indecipherable documents add an unnecessary level of complexity to an already-difficult situation. 

Even when every page is clear and legible, inaccurate information can easily appear in medical records. Forms that belong to one patient are found in a different patient’s chart about 5% to 10% of the time. This is easily identified and remedied. It’s a little harder to spot the medical record that has incorrect information, though sometime you can do this by analyzing the records, observing patterns of charting and learning the typical content that medical professionals chart about the patient in question. 

For example, a Legal Nurse Consultant may read a chart wherein the patient was consistently described as being confused. On one particular shift the nurse noted that the patient was alert and oriented "times four," meaning that he knew his name, the date, where he was, and the events leading up to that assessment. The LNC would know from having reviewed hundreds of pages of medical records that in fact the patient was never oriented; rather, he was consistently confused. Therefore, it's reasonable to conclude that the nurse entered incorrect information and made a charting error. 

Sometimes distraction, fatigue, rote charting and other factors result in inaccurate information getting into medical records. At times, caregivers may be using the documentation system incorrectly. They might not have received a proper orientation to the system, or may not know how to correctly complete the forms. The forms may even be confusing or redundant. Regardless the cause, while all of these situations are concerning, none of them is intentional.

“Dictated and Not Read” Is No Defense
Among non-deliberate charting errors are reports marked “dictated and not read.” It's likely that you’ve seen these in physician office records. The physician dictates a chart entry, and then at the bottom it says “dictated and not read.” Many physicians have, at some time, used a transcription service for patient progress notes. "Dictated and not read" is often added into medical records in the mistaken belief that it’s a valid disclaimer, excusing the doctor from correcting errors on transcribed reports. To the contrary, this practice can increase liability. The plaintiff's attorney can argue that the physician was too busy or too unconcerned to go back and review the medical record. A physician who uses voice dictation for his office records may see 25 to 30 patients in an eight-hour day. Though he promptly dictates his office notes, he may admittedly never have a chance to go back and determine whether the transcription service accurately transcribed his voice. Production pressure can easily contribute to a habit of not reviewing records after dictation, creating an increased risk for malpractice. 

Nonsensical Charting
You will occasionally spot data in medical records that doesn't make sense. You may notice only one outlying mention of a concern that logically should be seen elsewhere in the chart. The one-off nature of the note calls it into question. Similarly, rote charting can result in meaningless entries. For example, a nurse (as a matter of routine) may document that the call bell was within reach of a patient who was comatose and had contracted arms. That person was not going to use the call bell, so the note seems out of place. 

Other common examples of nonsensical charting: 

  • Incontinent patient who has “no difficulty voiding”
  •  Immobile patient on bedrest who has a “normal gait”
  • Patient who was unable to eat allegedly consumed 100% of his meal

How do these errors occur? Is it because the staff is not paying attention? Is it rote charting? Is it because the staff member is just clicking through the fields of a too-familiar form? These types of charting errors are concerning, but they're more indicative of sloppy charting than of fraudulent medical practice.

Requirement to Provide Accurate Medical Records
Various local, state, federal and regulatory agencies emphasize the need to create accurate medical records. These agencies audit medical records for inaccuracies as an extra layer of accountability. Caregivers know that the standard of care is to keep timely and accurate medical records. 

When questioning caregivers, it's effective to focus on correct documentation and what was included in the medical record. Zero in on the above-mentioned standard of care: Records are supposed to be accurate, complete and informative to other people who are taking care of the patient. 

Questions you might ask a healthcare provider:

  • Would you agree that it's a requirement of your job to document?
  • Would you agree that (this federal regulation) sets forth a standard of care in documenting patient care?
  • Would you agree that if it were shown that someone doing your job failed to (insert standard here), that would be a deviation from the standard of care?

In all of these examples, the caregivers concerned are contributing to inaccurate records, but they are not intentionally entering fraudulent information into patient records. Errors in medical records, regardless of cause, may be difficult to tease out for the non-medically trained. Legal Nurse Consultants can close the knowledge gap and arm you to present a thorough and airtight case in court. 

Next Post: Suspicious Inaccuracies in Patient Records