Posts Tagged ‘altered medical records’

Pat Iyer’s 9 tips on detecting altered medical records Part 5

Monday, July 12th, 2010

writing prescription• 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. 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.

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

Wednesday, July 7th, 2010

• Look for the “too good to be true” pattern of documentation. For example, the patient was steadily writing prescriptionlosing 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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Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 3

Monday, July 5th, 2010

• Examine handwriting to see if there are obvious changes in the appearance of the writing within an writing prescriptionentry. Another thing to look for is a change in style. If notes are sloppily written and suddenly a page of neatly written notes appears from the same author, this may be a sign that the page has been rewritten at a later date.
• Look for red flag notes. Sometimes the individual will leave a note behind that states that a record has been changed. For example, a medical record included a page that contained a handwritten note that stated, “Phyllis, substitute this page for the evaluation completed 5/6/04.” The page was copied with the handwritten note on top of the clinical record.
• Be aware of a typed entry that follows handwritten entries, or vice versa.
• Look for discrepancies from the type of charting that is required by regulations and facility policy.
• Look for an excessive number of late entries, especially involving circumstances surrounding the act or injury in question. Examine the timing of the late entry. Sometimes the healthcare professional adds a late entry after learning of a problem. Review the chart to see if there were other intervening opportunities for the healthcare professional to add the late entry before the time of discovery of a problem.
• Look for words that are squeezed into an entry.
• A half sheet instead of a full page of a medical record may be found. Careless photocopying could have occurred, but it is also possible that the page was cut or folded over to hide information.
• When reviewing the original medical record, look for a photocopy of a page that has replaced an original.
• Look for obliteration of entries. Was correction fluid or heavy marker used to cross off entries?
• Review the original record to detect different color ink used within the same entry. This will not show up on a photocopy unless a heavy felt tip pen is used as one of the writing instruments. Even a slight change in the color of the ink suggests that two different pens were used to create the record (the implication being that one part of the record was added at a later date).
Compare the family’s photographs of the patient with the medical records. Are there pressure ulcers in the photographs that are not described in the medical records? Are the patient’s tongue and teeth green with mold, but the medical records document daily mouth care?
• If photographs of a pressure ulcer are available ask a clinician to compare the stage of pressure ulcer in the photographs with what is documented in the medical records.

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

Wednesday, June 23rd, 2010

writing prescription• 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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Posted in Healthcare Risk Management, Legal nurse consulting, Medical records, Medication errors, Nursing malpractice, Tampering with evidence, Trial lawyer skills, medical errors | No Comments »

Why risk tampering with medical records? By Pat Iyer

Wednesday, November 4th, 2009

Altering medical records has huge consequences

Altering medical records has huge consequences

A physician gets a notice that he is being sued. He gives into the temptation to review his office records. He decides to change an entry to 1. More completely describe events 2. Make it look as if he did something that he did not. But it is way too late. The plaintiff attorney and her legal nurse consultant already have the record and spot the change when they receive a second set of medical records. A charge of spoliation of evidence is added to the suit.

What is the impact on the person who tampers with medical records?

1. Insurance coverage
A medical malpractice claim that includes an allegation of alteration of records may not be covered by a commercial professional or individual’s liability policy. The insurer may reserve its rights to not pay any judgment that might be entered against the provider. Institutional providers participating in self-insured trusts may have similar coverage limitations. Some states recognize a separate cause of action for alteration of medical records, whereas other states deal with it as a jury charge. If the provider admits that he or she has made the alteration, the policy may be completely voided, including coverage for the medical negligence, depending on the state law. An individual who has his or her own insurance policy may find the carrier refusing to renew the policy the following year after the insured was found to have altered records or on whose behalf a settlement was paid in a case involving alleged alterations.

2. Regulatory agencies and privileges
Some state regulatory or licensing boards may investigate the healthcare provider. Disciplinary action may follow. The healthcare system that has provided privileges to the healthcare provider may be reluctant to allow that individual to continue on the staff. Those who falsify medical records risk more than just the loss of a malpractice case. Medical boards have been known to suspend or revoke the licenses of healthcare professionals caught tampering with records. In January 2009, a physician in London lost his license to practice for a year after a disciplinary inquiry showed that he engaged in a sexual relationship with a patient, tampered with and or improperly caused inaccurate changes to be made in her records, and failed to keep accurate records. He also failed to record details of her visits, medical condition, and results of medical examinations, and failed to maintain patient confidentiality by improperly disclosing to his lover confidential information related to the care of two patients.

3. Shame and embarrassment
Loss of reputation, shame, guilt, and being exposed as a wrong doer can all have a profound impact on the individual who altered medical records. A British physician hid her error for 16 years before confessing. When she was 26-years-old and working as a junior physician, she made a medication error that resulted in the patient’s death within an hour. She changed her chart entry to make it appear she had prescribed a smaller dose of the medication than had been ordered. She was questioned by police and later gave evidence at an inquest but did not tell anyone what she had done. In 2001, she could not live with her guilt any longer and wrote a letter to the patient’s family confessing her mistake. After an investigation and a formal written warning, the General Medical Council decided to allow her to continue practicing.

4. Criminal/civil offenses
In many states, falsification of medical records is also a criminal offense punishable by fines and incarceration, see e.g., California Penal Code §471.5. The Healthcare Insurance Portability and Accountability Act was used to put a Pennsylvania nurse in prison who altered nursing home records.

Most healthcare providers who tamper with medical records have a mistaken belief that their actions cannot be detected. The guilt or fear of being found negligent swamps their good judgment.

Med League assists attorneys who suspect tampering with medical records by performing chronologies and timelines that identify discrepancies. Please note that our ethical codes prohibit us from working with people who have not yet retained an attorney.

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