Over the last several months I've detailed the complexity of organizing and analyzing medical records. Clearly, it takes a great deal of time to do this task justice. If just anyone could read medical records, you wouldn't need someone with medical background to assist in correct interpretation and preparation (the keys to any successful case)
Electronic medical records (EMRs) produce new—and sometimes confusing and voluminous—documentation. Understanding the implications of the transition from paper to electronic record, both generally and specifically, helps you make sense of all of this information.
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.
Your analysis of medical records shows that a provider tampered with medical records. You have a healthcare provider or possibly a documents examiner confirm your suspicions. Here is what can happen next.
Legal cases often arise because of conflict over medical care. Whether representing plaintiff or defendant, you need thorough and accurate patient records to construct your case and serve your client. For legal professionals handling medical documentation, it's imperative to know what tampering looks like and how it happens.
When you uncover inaccuracies in medical data, they may well be a result of unintentional error, but sometimes the alterations will look more intentional. In my last blog post, I homed in on these suspicious inaccuracies; this week, I'll shine a spotlight on some typical tampering incidents.
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.
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.
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.
This post wraps up an ongoing series on managing and organizing medical records; here we provide a review of some of the topics discussed in the series, plus our Top 10 Hints for Medical Record Management.