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.
Despite our rapidly-advancing digital age, obtaining a complete copy of an electronic medical record (EMR) can prove to be a significant challenge. Unlike paper records, which are commonly organized in a specific fashion, electronic records often make little sense when simply printed out.
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.
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.