Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 2

• Compare the nursery records generated at birth with those sent to the hospital to which the baby is transferred.
• Review the copies of hospital records found within a physician’s office records with those supplied by the hospital.
• In most hospitals, the mother’s labor and delivery record is normally 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 added additions to a set of records.
• Often, copies of a record are supplied to others in the ordinary course of treatment long before a problem or an attorney appears on the scene. The record examiner should not assume that the records supplied in discovery are identical to the ones supplied to others before a problem manifested itself. It is not unusual for a doctor referring a patient to a specialist 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 sometimes sent to the subsequent treating doctor. These records need to be closely compared to see if there are any additions.
• 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?
• Compare the set of records obtained by the plaintiff prior to litigation with the set provided after the plaintiff’s attorney requested 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.
• Observe 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.
• 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 that restricted access to the chart was in place. This has likely occurred because of an unexpected outcome or a suspicion of wrong doing.
• 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 of other staff members or professionals after an incident occurred.

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips at www.medleague.com.

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