• Examine logs or communication books kept at the nursing station of some nursing homes. I found a note in a nursing home communication book that stated, “When you recopy the nurses’ notes, leave enough room for the night shift to describe the fall.” The case settled soon thereafter.
• Obtain billing records to determine if care was charged for but not documented. Medical coding and billing errors pop up from time to time. A record of an office visit may have been removed from the file, but the billing record verifies that the patient was seen.
• Sometimes there will be a dispute over when or how frequently a patient was treated and what diagnosis was made by the physician at that time. These disputes can often be resolved by requesting a copy of the medical insurance company’s records and comparing the billing records and diagnosis codes with the doctor’s records.
• Evaluate the hospital or nursing home’s staffing records to determine if the people who have documented in the medical record actually worked that day.
• Look for any documentation in the file indicating when the chart was copied and to whom it was supplied. Request copies of the chart from these entries and compare the two sets.
• Request a copy of the facility’s policy on documentation.
• Request the policy on incident reports.
• Request copies of physician office scheduling books to determine when the plaintiff was supposed to have been seen in the office.
• Request records of companies employed to act as answering services for physicians.

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.