“I think the hospital is tampering with medical records.” “My physician’s office records are missing the visit during which I fell off the examining table.” “My doctor wrote things that are not true.”

We get calls at Med League from people who are suspicious about the accuracy of their medical records. Med League has published several articles about tampering with medical records that come up high in search engine results on this topic. 95% of the people who contact us are not being represented by attorneys. We explain that we cannot work with pro se clients and suggest sources for finding an attorney.

The attorney should be aware of the potential for tampering when:

• a provider learns that a plaintiff’s attorney is seeking a copy of the medical record.
• the plaintiff’s story is different or conflicts with the documentation.
• the medical record is missing or incomplete.
• there is little or no documentation about an event or incident that resulted in harm to the plaintiff.
• the result of the injury is not consistent with the documentation.
• the plaintiff’s complaints are consistent with the missing information.
• there is a delay in or an inability to obtain medical records.
• there is too good to be true documentation such as perfectly stable weights or vital signs which do not vary.
• an unexpected event has occurred, such as an escape from a healthcare facility, an injury, fracture, birth injury, surgical error, death, burn, or whenever there is a medical catastrophe.
• a hospital acquired condition develops such as a stage III or IV pressure sore, air embolism, retained sponge, and so on.

This source addressed the responsibility of facilities to maintain records:

“The health records of patients involved in potentially compensable events and claims should be completed as soon as possible after the patients are discharged. The primary and secondary records should then be copied for use by the risk manager and the originals secured in a locked storage place. Any written incident reports, investigative reports, peer review records, and credentialing files relevant to the case also should be protected. State laws and findings in past legal cases dictate what kinds of information must be provided to the parties in a lawsuit, and risk managers should maintain the confidentiality of sensitive documents until it is determined exactly what kinds of information must be turned over to the injured party’s representative. Patients and their legal representatives have automatic access to the patient’s health records, and so copies of internal incident reports must not be placed in health records.” (2)

Joint Commission, state and federal regulations address the need to maintain accurate and complete records. Nurses and physicians can be disciplined by their boards of licensure for documentation errors, lose insurance coverage, or be charged with a crime.

The stakes are high. Yet why do healthcare professionals alter or destroy records? There are many reasons why a person would tamper with records, including an intention to commit fraud, such as billing for services not performed, or fear or guilt when an untoward outcome occurs.

1. Intent to commit a fraud due to greed – this includes billing for services not rendered or making deliberate billing errors.
2. Fear of being exposed or harmed by damaging information – when a bad outcome occurs, a diagnosis is missed, the guilt associated with this may lead the healthcare provider to review prior records and add information to them.
3. Notification of being sued – the healthcare provider may not realize that the patient (and his or her attorney) already possesses the records.

Any additions or deletions to records will be detected if the attorney requests a second set later in the litigation. Many of our plaintiff attorney clients make this a practice and some have been amazed by what they’ve discovered.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.

References:

(1) Merida Johns, Health Information Management Technology, American Health Information Management Association

(2)  “Tampering with Medical Records”, Medical Legal Aspects of Medical Records, Second Edition, 2010.