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. When a physician or nurse learns that they're being sued, it's a safe assumption that the plaintiff attorney already has a copy of the medical record. This makes "panic notes" a particularly serious problem. Sharp plaintiff attorneys will request a second copy of the medical record after the case is in suit to see if the provider makes changes in the medical record.
Similarly, another type of suspicious medical record may contain duplicate information in a patient chart, yet the two pieces of data reflect inconsistencies. This raises questions about which piece of information is accurate. In both these situations, legal nurse consultants (LNCs) are ideally suited to compare the two copies of the medical record and unearth any evidence of tampering.
Tampering with Medical Records
There are several components of spoliation, or tampering with medical records. To qualify as spoliation, the record must reflect one of the following:
- Actual or attempted destruction: The destruction may be unsuccessful because someone has kept a copy of the original medical record.
- Suppression of medical records or evidence: Medical records are withheld.
- Failure to preserve evidence: A faulty IV pump involved in an incident was destroyed instead of being retained, for example.
- Creation or fabrication of evidence to support a defense or a claim
Red Flags for Tampering
Watch for these common indicators of possible tampering:
- An unexpected event (including but not limited to an escape from a healthcare facility, an injury, a fracture, a birth injury, a surgical error). Look for outcomes generally considered to be medical catastrophes.
- Missing, delayed, or incomplete medical records raise questions about whether someone is trying to change or alter records, or may be stalling to avoid providing them.
- Little or no documentation about a harmful event raises questions about tampering.
- An injury is inconsistent with the documentation. You may feel like you are looking at two different sets of facts.
- Documentation is too good to be true. It's inconsistent with clinical realities. Clinically, it is unlikely that somebody can go for four hours with perfectly stable vital signs with exactly the same pulse, respiration and blood pressure. That’s a “too good to be true” vital sign record.
When a patient's medical record contains strong evidence of tampering, there are immediate implications for the medical provider(s), the patient and legal next steps.
Next Post: The fallout of illegal tampering