Medical records alteration, while not the rule, happens more often than we realize. While many of these changes are made without ill intent, there are times when a provider is illegally tampering with records to cover a trail of negligent medical care. The tips below will help researchers ferret out inconsistencies in patient charts, possibly leading to a legal win for the client.
First Things First
- Always keep a list of records that have been requested to verify everything has been received.
- Determine whether the medical record entries are correctly sequenced and dated within the correct time frame. For example, a physician recopying an office note may inadvertently use the year in which the change is being made, rather than the original year for the chart entry.
- Search for discrepancies in dates. Entries may be inconsistently dated.
- Examine the chart for discrepancies in times or entries that are not in the correct chronological order.
- Look at the dates when treatments or medications were ordered versus the dates they were given.
- Ask your LNC to create a chronology of care with the dates of admission and discharge. Look to see if care was charted after the patient left the facility.
- Notice when medication is charted as being administered after the patient left the facility.
- Note records that oral medications were being administered when the patient was supposedly comatose and unable to swallow.
- Compare the condition of the patient on the day of transfer from one facility to another. Look for discrepancies in the description of the condition of the patient. For example, a pressure ulcer’s presence may be not mentioned in a hospital chart but is documented in detail when the patient arrives at a nursing home.
- Are the observations of the physicians with those of the nurses consistent?
- Notice any entry made by someone who significantly erred in treatment, particularly if the entry is at odds with the rest of the chart.
- Examine the typical way in which the healthcare professional documents. Are notes routinely brief, but become unusually detailed on the day of an incident?
Examine From Every Angle
- Compare a set of original medical records with that supplied to the attorney. Use sticky notes to indicate next steps.
- Whenever two sets of records are located, compare them. For example, compare the prenatal chart kept by the obstetrician with the prenatal records sent to the hospital prior to the labor and delivery.
- Compare the nursery records generated at birth with those sent to the hospital to which the baby is transferred.
- Review copies of hospital records found within a physician’s chart with those supplied by the hospital.
- In most hospitals, the mother’s labor and delivery record is copied and placed into the newborn’s chart. The copy from the mother’s chart must be closely compared with the copy from the newborn’s chart in order to see if there are any additions to a set of records.
- Consider specialists. It's not unusual for a primary care physician to send a copy of the patient’s chart to the consulting doctor. Likewise, when a patient changes providers, a copy of the first doctor’s chart is often sent to the subsequent treating doctor. Closely compare these records to see if there are any additions.
Everything is Suspect
- Examine handwriting to see if there are obvious changes in the appearance of the writing within a single entry.
- Keep your eyes open for a change in style. If notes are sloppily written and suddenly a page of neatly written notes appears from the same author, this may be a sign that the page was rewritten at a later date.
- Look for red flag notes. Sometimes an individual will carelessly leave hints of a change. For example, a medical record included a page that contained a handwritten note: “Phyllis, substitute this page for the evaluation completed 5/6/16.” The page was inadvertently copied with the handwritten note on top of the clinical record.
- Be aware of typed entries that follow handwritten entries, or vice versa.
- Look for departures from the type of charting that's required by facility policy and regulations.
- Look for an excessive number of late entries, especially involving circumstances surrounding the act or injury in question. Note the timing of the late entry, because the healthcare professional may add a late entry after learning of a problem. Review the chart to see if there were other opportunities for the healthcare professional to add the late entry before the problem was discovered.
- Look for words that are squeezed into an entry.
- You may find a half sheet instead of a full page in a medical record. While it may result from careless photocopying, it's possible that the page was cut or folded over to hide information.
- When reviewing the original medical record, look for a photocopy of a page that has replaced an original.
- Look for obliteration of entries. Did a healthcare provider use correction fluid or heavy marker to cross off entries?
- Note different ink colors used within the same entry. This may not show up on a photocopy. Even a slight change in the color of the ink suggests that two different pens were used to create the record (implying that one part of the record was added at a later date).
- Compare the family’s photographs of the patient with the medical records. Are there pressure ulcers in the photographs that aren't described in the medical records? Does the presence of green mold on the patient’s tongue and teeth contradict the medical records’ documentation of daily mouth care?
- If photographs of a pressure ulcer are available, ask a clinician to compare the stage of the ulcer in the photographs with what's documented in the medical records.
- Look for the “too good to be true” pattern of documentation. For example, the patient was steadily losing weight but supposedly consuming 100% of his 2000 calorie-per-day diet.
- Note entries that are self-serving with excessive explanation of the events.
- Look not only at the content of the records but also at the extraneous details of the whole record. (People commonly focus on the overall message without seeing the details.) Step back from looking at the overall content and, as a separate step in the review of the records, focus on extraneous details.
- Look at the bottom of a questionable form to see if the facility stamped the date of printing. Compare the date of the form with the date of the entries.
- Always ask to examine the original records. Often, codes appear on the back side of a page. Review the original to determine what codes are applicable to both sides of the page.
- Examine logs or communication books kept at the nursing station of some nursing homes. An LNC found a note in a nursing home communication book that stated, “When you recopy the nurses’ notes, leave enough room for the night shift to describe the fall.” That case settled soon thereafter.
- Obtain billing records to determine if care was charged for but not documented. Medical coding and billing errors pop up from time to time. The record of an office visit may have been deleted, but the billing record verifies the patient was seen.
- Sometimes there will be a dispute over when or how frequently a patient was treated and what diagnosis was assigned by the physician. These disputes often can be resolved by comparing the insurance company's billing records and diagnosis codes with the doctor’s records.
- Evaluate the hospital or nursing home’s staffing records to determine whether the people who documented medical care actually worked that day.
- Look for any mention of when the chart was copied and to whom it was supplied. Request copies of the chart from these entries and compare the two sets.
- Request a copy of the facility’s policy on documentation.
- Request the policy on incident reports.
- Request copies of appointment schedules to determine when the plaintiff was expected to be seen.
- Request records of answering services for physicians.
- Compare the letters and reports written by physicians when they are found in more than one set of records. Are the letters identical, or does one set of records contain fewer or different reports?
- Look for a stamp or mark (usually on a face sheet) that indicates that the chart was kept under the control of the Risk Management Department or the Health Information Management Director’s office. This indicates restricted access to the chart was in place. This has likely occurred because of an unexpected outcome or a suspicion of wrongdoing.
- Note descriptions of the patient that may reveal antagonism between the patient and staff. A bad clinical outcome may lead to the temptation to alter records.
- Note finger pointing or blaming among staff members or professionals, particularly after an incident occurred.
Utilize Legal Resources
- Request an audit trail whenever you suspect altered electronic medical records.
- Compare the set of records obtained by the plaintiff prior to litigation with the set provided after the plaintiff’s attorney requests the records.
- Compare the set of records obtained early in litigation with those obtained shortly before resolution of a claim.
- Compare a set of records supplied to the plaintiff with those supplied to a regulatory agency.
- Hunt for new entries added to later copies of the record, or pages that are missing from the first set of records. Look for additional pages that were not supplied with the first request for records.
This laundry list of pointers may point you in the right direction in your medical case. With an LN in your legal stable, you increase your odds of achieving the best possible outcome for your client.