Pat Iyer’s 7 tips on detecting altered medical records part 4

• Look for the “too good to be true” pattern of documentation. For example, the patient was steadily losing weight but supposedly consuming 100 percent of his 2000 calories per day diet.
• Note entries that are self-serving and needlessly explanatory of the events that occurred. 50
• The medical record examiner needs to look not only at the content of the records but also at the extraneous details of the whole record. Psychologists have long observed that people normally focus on the overall message without seeing the details. The astute record examiner needs to 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 has a date of printing on the form. Compare the date of the form with the date of the entries.
• Determine the meaning of codes at the bottom of a form. For example, a progress note was supplied to an attorney in discovery by a physician being sued for medical malpractice. The preprinted form on which the doctor kept his notes contained a code (0595) and the manufacturer’s telephone number. A quick call to the stationery company that created the form revealed the code was actually the date the form was created. The physician was caught in a flagrant lie with no way to explain how an “original” progress note from 1994 could end up on paper manufactured in May of 1995.
• Always ask to examine the original records. Often, codes appear on the back side of a page. The examiner needs to review the original in order to determine what codes are applicable to both sides of the page. Also, if there is no written entry on the back side of the form, it is not normally copied or supplied in discovery even though it may contain preprinted codes. The person doing the copying normally views a page without handwritten or typed entries as a blank page and will not copy it.

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.

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