Altering medical records does not happen as often as it appears to happen on television or in the movies. However, it happens enough that experienced medical malpractice lawyers develop a sense of when further investigation into the legitimacy of a medical record or chart is warranted.
One of my favourite movies of all times is The Verdict with Paul Newman. I love the scene where he finally realizes that he can prove that the defendant doctor altered the medical files of the woman who was left in a coma because of the doctor’s negligence.
Lessons Learned From Past Cases:
Over the past 18 years, I have learned some lessons about when to suspect that a medical file may have been altered.
Notes on one report, not on another:
In one case I was involved in the specialist’s report that was received by my client’s family physician did not have (exculpatory) handwritten notes that appeared in the report in the specialist’s file.
Look for all copies of the record and compare them.
Different Versions of reports:
In one case the surgeon dictated three different versions of the operative report. The family doctor received the first version days after my client’s surgery. After my client’s condition deteriorated, he dictated a second version (which was found in the Hospital chart). After my client became comatose and was transferred to another hospital for corrective surgery he dictated a third version of the report which was in his office copy of my client’s chart.
Get the records, and get them fast.
Were they working?
In a claim involving allegations of nursing negligence, the nursing notes contained statements that the patient’s condition had been communicated to the attending physician. However the date of the entry was for a day that the nurse in question wasn’t working!
Compare staffing sheets/time cards with the medical chart to detect entries/notes by staff members that were not present/on duty that day.
Medication errors are a common mistake among nurses who are overworked or inexperienced.
In a claim involving a fatal overdose, the nursing notes indicated that the deceased had received the proper dosage of medication. However, the medication administration records, which were not supplied by the hospital when the chart was originally requested, showed that the medication had been administered to the patient twice.
Compare the medication administration records with the nursing notes and physicians orders.
In an anesthesia negligence claim the anesthesiologist tore up the original anesthesia record and prepared a new record with different data. One of the nurses involved in the operation retrieved the original record and scotch taped it together.
Interview everyone, including retired employees.
White out = Suspicious Records
In a birth injury claim two of the babies APGAR scores had been whited out and changed from a 0 to a 2 (normal).
Change the Numbers – Change the Result:
In a fatality claim the deceased’s blood pressure reading had been changed from 170/90 to 120/80 by using a different colour pen to alter the numbers 7 and 9. The change couldn’t been seen on the photocopy of the patient’s chart, but was reasonably obvious on examination of the original chart.
Whenever I have a reasonable suspicion that the medical files have been altered, I make an appointment to attend at the Hospital or the doctor’s office to view the original chart.
What to Look For:
Some “red flags” that I look for, based on past experience, that may indicate the possibility of altered medical records are:
• Crowding or squeezing entries above a signature, or between lines;
• Erasures, crossed out entries or white-out corrections;
• Changes in slant of handwriting;
• Using different pens or computer typeface to write one entry;
• Notes on different dates in the same colour ink from same pen;
• Notes in different colour ink (different pen) in the same chart note;
• A typed entry following handwritten entries, or vice versa;
• Missing original records that have replaced by photocopies;
• Entries that are self-serving;
• Half sheets instead of the standard size page (page cut in half);
• Additional notes on the original document, not on copies received by client;
• An unusually late date of dictation of a consult report;
• Any handwritten entry made by someone who erred significantly in treatment.
If you are looking for a Nova Scotia Medical Malpractice Lawyer you can contact me for a free copy of my book: The Consumers Guide to Medical Malpractice Claims in Canada: Why 98% of potential medical malpractice victims never receive a penny in compensation.
If you believe you or a family member believe you may have been injured as a result of medical malpractice you can contact me through this blog, or call me toll free at 1-877-423-2050.