Detection of Tampering with Medical Records Toolkit

Detection of Tampering with Medical Records Toolkit

For Plaintiff Attorneys, Legal Nurse Consultants, and Paralegals

Patricia W. Iyer, MSN, RN, LNCC

96 pages

2005, Med League

Price: $60.00

Special offer: Buy this product and either Medication Errors video or Nursing Home Liability video and save $20.00!

Table of Contents

Whether you are an attorney or legal nurse consultant, you will gain from reading this toolkit. Expert Patricia Iyer presents information on detection of tampering with medical records in a practical manner. You will learn the legal implications of tampering and how to detect tampering. Included are many actual examples of altered records. (See also our product for administrators, risk managers, and defense attorneys.)

The 96 pages of content cover these topics:

  • substandard charting
  • suspicious charting
  • definitions of spoliation
  • spoliation inference
  • implications of spoliation
  • organizing medical records
  • techniques for tampering with medical records
  • detection of tampering
  • strategic decisions
  • defense of spoliation claims

Also included are three checklists:

  • Is there reason to believe that the medical record may have been tampered with?
  • A blueprint for organizing medical records
  • Strategies for detection of tampering with medical records

as well as 35 slides of examples of altered records and descriptions of almost 30 legal cases involving tampered records.

The material in this toolkit has been assembled over years by an experienced legal nurse consultant and author of two chapters on tampering with medical records:

Patricia Iyer, Nursing Home Litigation: Investigation and Case Preparation, Second Edition, 2006.

Patricia Iyer, Barbara Levin, and Mary Ann Shea, Medical Legal Aspects of Medical Records, 2006.

Table of Contents

1. Introduction
2. Substandard Charting
Incomplete charting • Untimely charting • Illegible handwriting • Incorrect charting
3. Suspicious Charting
Detailed addenda • Duplicate information
4. Definitions of Spoliation
5. Spoliation Inference
6. Implications of Spoliation
Effect on the case • Jury charge • Effect on the healthcare provider: Insurance coverage, Regulatory agencies and privileges, Criminal/civil offenses • Tampering by attorneys • Remedies for the person harmed by spoliation
7. Organizing Medical Records
Compiling records • Other documents and items to review
8. Techniques for Tampering With Medical Records
Adding to an existing record at a later date • Placing inaccurate information into the record • Omitting significant information • Changing numbers • Rewriting the record • Destroying records • Adding to someone else’s notes
9. Detection of Tampering

Incident report • Examples of allegations: Pressure ulcers, Malnutrition and dehydration, Physical and sexual assault, Falls and fractures, Elopement, Birth trauma, Surgical errors
10. Strategic Decisions
Document examiners • Discovery requests • Use of interrogatories
11. Defense of Spoliation Claims
Elements of proof • Proactive approach with defendants • Credibility
12. Summary
Checklist 1: Is There Reason To Believe That The Medical Record May Have Been Tampered With?
Checklist 2: A Blueprint for Organizing Records
Checklist 3: Strategies for Detection of Tampering

Related products:

With Patricia Iyer as author, editor, or contributor

Detection of Tampering with Medical Records Toolkit for Administrators, Risk Managers, and Defense Attorney

Falls Handbook

Guide for Assessing Hospital Liability: A Former CEO’s Perspective

Medical Legal Aspects of Medical Records

Medication Errors video

Medication Errors Toolkit

Nursing Home Liability video

Nursing Home Liability Toolkit

Nursing Home Litigation: Investigation and Case Preparation

Paralysis from a Medical Error