There are several mechanisms for tampering with medical records. While tampering can occur with either handwritten or electronic records, it's far more obvious in handwritten records. There are several places to look when checking for altered records. The following are the most common examples.
A common method of altering medical records is the addition of content at a later date. A healthcare provider may write a "panic note" directly after an incident, or even months or years later when a s/he finds out that s/he is being sued. Risk managers know there’s a temptation to alter the medical record under these circumstances, and they may lock a physical chart in their office to protect a provider from that urge.
A provider may squeeze words into an entry or rewrite a record with additional details. For example, a young girl in a psychiatric facility needed to have a submucous resection for chronic tonsillitis. After surgery, the surgeon completed the surgical progress note with details about the procedure and sent the patient back to the psychiatric facility. She started bleeding, and the psychiatric nurses were unfamiliar with caring for a post-operative tonsillectomy patient. The patient continued bleeding and suffered resultant anoxic brain damage.
Later, when the medical record was reviewed, two versions of the postoperative note were discovered. The surgeon added a statement to the second version that stated “Relatively comfortable post OR. No bleeding. Instructions given to attendants before patient went back to the hospital.” It is not clear why the surgeon did not discard the first version of the note, which did not mention bleeding or instructions, but the presence of conflicting records is suspicious.
A nursing home case involved a resident who had a tracheostomy tube, and a pattern of trying to pull the tube out. Ultimately she was successful, and she was found dead in her bed with the tracheostomy tube in her hand.
The director of nursing ordered all nurses taking care of the patient for the preceding two days, as well as the day of the incident, to rewrite their notes. Each of those nurses was unhappy about and resistant to the unethical order, but most complied; one nurse reported the request to top management. The director of nursing kept the original medical record, as well as all of the rewritten ones. He didn’t destroy the original notes, so when the Department of Health performed an investigation, they found both sets of notes.
Initially, the nursing home hid the actual cause of death from the family. A month later another resident in the same facility pulled out her tracheostomy tube and died. This received local media attention. The family of the first resident read an article that said, “This is the second such incident" and mentioned the first incident. They made the connection and contacted a plaintiff attorney who settled the case. The altered records left the nursing home vulnerable to litigation.
Sometimes, when requesting records from multiple providers, you can compare records from one facility with the pages of the same record when it was sent to a different facility. You may find new information added to a record, or even a rewritten version.
Healthcare administrators are generally aware of the risks of late entries, and they would prefer to restrict access to records rather than allow a provider to change or add information. There are situations, however, when an addition to the record is necessary, such as when the provider missed or inaccurately charted information. Some administrators give staff the freedom to enter the corrected or additional information as a late entry; others require the supervisor to review the intended addition to assure that the record is not being tampered with.
Providers may tamper with medical records by inserting inaccurate information. False information can sometimes be very hard to detect. It often requires a Legal Nurse Consultant's (LNC's) clinical knowledge to uncover. Inaccuracies show up in several common forms.
Recording Care That Has Not Been Delivered
Plaintiff attorneys who handle nursing home cases routinely see this type of issue, which is documenting care after the nursing home resident has left the facility. Sometimes nursing assistants fall into a pattern of rote charting and mindlessly make entries on the charts of residents who are not even in the building.
In one example, a nursing home resident was admitted to a hospital on September 9th. He was then discharged from the hospital and admitted to a rehabilitation center on September 11th. However, back at the residential nursing home, the aides continued to record his meal intake for the 10th and bowel elimination details on the 10th and the 11th. They recorded his food intake and bowel elimination on the 13th. All of this time, the patient was offsite.
Your understanding of the mechanism of injury is key, and may help you appropriately question a charting entry. A nursing home resident was found on the floor. The nursing home nurse documented the incident report. She or he wrote that the bed was in a low position just inches from the floor. There were supposedly mats on the floor. The nurse documented that the resident developed swelling on the side of her head and sustained a small skin tear on her left arm.
These notes don't describe a serious incident. But the patient subsequently died, and the autopsy report listed the cause of death as blunt impact injuries, subdural and subarachnoid hemorrhage, cerebral shift and fracture of the cervical spine. This is not congruent with the description of the incident. The geriatrician who reviewed this case opined that it was clearly not possible to sustain this type of injury from the description of that event.
In another case, a woman was in the hospital for 7 months. The facility used flow sheets to record the times the patient was turned. The flow sheets showed that she was turned every two hours around the clock. Nonetheless, she developed Stage III and Stage IV pressure sores. The facility’s policy stated that nurses were to document the exact time she was turned. There was not a single time in seven months that the patient was turned at any time other than the ones recorded on Figure 2.1. There were also blanks on the form as you can see. The woman’s daughters took her home, turned her every two hours and within one month, the sores were healing.
The plaintiff attorney and defense attorney literally settled the case in the hallway.
Here is an example of charting in a billing fraud case. Figure 2.2 shows the notes of a physical therapist who documented giving therapy on 10/13, 10/15 and 10/29. The man died on 10/11. See his death certificate, below, in Figure 2.3.
Another method of tampering with medical records is charting before care is given. Nurses anticipate what will happen, and then chart accordingly.
In a nursing home case, a resident developed a reddened wound. The nurse documented on 12/27 that “antibiotics were started as ordered.” The order for the antibiotics was actually written on 12/30. How did the nurse know on 12/27 that antibiotics would be ordered on 12/30?
Another aspect of tampering with medical records is omitting significant information. Providers may fail to record information about an incident. You might stumble across such a situation.
In a hospital case, there was a sticky note on a medical record stating that, “Shauna reviewed and marked notations regarding the incident. Those PSS to Janice.” (PSS was the name of a computer system that they were using.) What’s curious is that there was absolutely no indication of any incident in the medical record. This sticky note sat on top of the page when it was duplicated for the attorney.
It’s easy to spot these discrepancies in handwritten records. It’s a little bit harder to see the flow of information with electronic medical records, but sometimes you can use common sense to realize that information is missing.
In an emergency department case, a man sat on the edge of a stretcher, calling for help to go to the bathroom. No one came, so he tried to get up on his own; he fell face first onto the floor and fractured several facial bones. The hospital defense attorney asserted that he fell because he had a seizure. The LNC who went through the emergency room record to help the plaintiff attorney found a 12-hour gap in charting while the patient was in the emergency room, including the time frame of the fall. There were zero nursing notes for that time period.
The defense attorney asserted that the facility supplied the full record. The LNC prepared an affidavit for the plaintiff attorney that said it was impossible for the patient to be in the emergency room for 12 hours without any documentation. The chart stopped at a certain point, and it began again after he was transferred to the medical surgical unit. The judge supported this position and ordered the defense attorney and hospital to turn over the documentation. The facility supplied the records, and the case settled shortly afterward.
In another case, a 300-pound man was in the hospital for back surgery. A 100-pound nurse’s aide attempted to get him out of bed by herself. He said, “I really think you should get some help. It took three people to get me out of bed this morning.” She said, “I’m strong; trust me.” She got him up with a walker but was not strong enough to assist him when his knees buckled, so he fell onto the floor. The roommate and the roommate’s wife witnessed the fall, but the nurse who was taking care of him that day wrote nothing in her nurse’s notes about the incident.
There was, however, one note in the medical record by the physical therapy student who described the incident. This verified the incident took place. See figure 2.4.
The Numbers Game
Tampering occurs when caregivers change data in medical records. In a nursing home case, nurses requested a speech language pathologist to evaluate a patient for swallowing ability. Although the request was made in February, either the request for the evaluation was not communicated to the physician or it wasn’t acted upon. The resident choked to death on food a month later. Someone found the consult and altered the date to change the 2 (for February) to a 3 (for March) to make it look as if there had been no delay in receiving a swallowing evaluation.
In a hospital case, a man received a great deal of pain medication in the recovery room. The nurse on the medical surgical unit did not check to see what medications he had received in the recovery room. She gave additional pain medication. His wife found him unresponsive; he subsequently died. The nurse testified that she walked in at 1900 hours, found that he had no blood pressure and that he was becoming unresponsive. She then altered numbers after his death. See figure 2.5.
When she was questioned about this, her statement was hard for the jury to accept. She testified in exactly these words, “My eights are not that great. As a matter of fact, with eights, I make twos.” At trial, her flow sheet was blown up and mounted on a foam core board and the jury had a great deal of difficulty believing in the accuracy of her testimony; ultimately they awarded a decision to the plaintiff.
It’s unusual to eliminate whole sections of medical records or pieces of medical records. It's a rare act of desperation.
A nursing home staff claimed that all the critical pages related to a liability issue were supposedly wet, destroyed and rewritten. Parts of the medical record that were not relevant to the issue were conveniently undamaged.
5 Hints for Detecting Tampering
An LNC’s careful review of medical records is invaluable in detecting tampering with medical records. They'll ferret hints of tampering that A less-experienced reviewer may miss. LNC's offer these tips for spotting tampering.
Look at where the description of an incident might be recorded. An incident may be detailed in these places:
- Nursing progress notes
- Physician progress notes
- ER records from a subsequent facility
- Operative report
- Discharge summary
- Progress notes of ancillary staff
- Notes from another facility
Compare all descriptions of an incident. Make note of whether the incident is described at all.
2. Changes in Writing Style
Look for changes in note styles. It is suspicious if a person who typically writes a brief note suddenly writes pages after an incident.
3. Pressure Sore Stages
Sometimes a hospital describes a pressure sore at one stage, but when the patient gets to the nursing home, it's described at a significantly more serious stage.
4. Phantom Staff
Staffing sheets will let you know if the healthcare staff who were charting were actually on duty at the time of the care they purportedly recorded. Ex-employees can be helpful in identifying patterns of charting or tampering with medical records.
5. Incomplete Discovery Documents
A key aspect of investigation is scrutinizing the discovery documents to see what’s been supplied. Are they complete? What’s missing?
Compare photographs and records. Sometimes staff members take pictures of pressure sores, for example, but the medical record's description doesn't match what an LNC sees in the pictures.
Examine With Care
Detailed analysis of handwritten and electronic medical records is tedious and time consuming. Legal nurse consulting involves meticulous analysis, combing through records and searching for discrepancies. At times, a documents examiner should get involved for more detailed analysis of the record. LNCs are a key support in tampering cases, helping deliver the evidence you need to bolster your client's case.