In the United States, medical records are personal documents and there are laws to protect them from unauthorized third-party access. In addition, medical records are legal documents that may not be falsified or altered in any way. A medical chart is a record of the treatment given to a patient and must be preserved as a means to refresh the memory and explain the rationale for the care rendered. For victims of medical malpractice, there is always a concern that negligent healthcare professionals will attempt to cover up incriminating evidence by falsifying the medical record.
If you or someone you love has received suboptimal care at the hands of healthcare providers, it’s important to understand the detection, prevention, and consequences of falsified medical records.
How do I know if my medical records have been falsified?
These days it’s easier to track changes as most medical records are electronic. To find out whether your medical records have been altered:
- Look for inconsistencies with other records such as medical bills which also contain diagnostic codes.
- Be vigilant for interruptions in the chronology (dates) of medical care and any deviation from the logical order of events.
- Obtain copies of records from other agencies such as your insurance company or other doctors and hospitals and compare them.
- Get a forensic expert to examine the records for inconsistencies (for example, ink differences) and perform a chemical analysis to determine if any manipulation of the medical record has occurred.
How can I protect my medical records from tampering?
When a patient or relatives allege medical negligence, the legal system relies heavily on documentary evidence. Studies have found that the majority of medical errors occur due to miscommunication. It can be challenging to obtain and maintain a clean record of all the communication between various healthcare professionals during medical care and treatment. To prevent any tampering of your medical records occurring and going undetected:
- Keep copies of all documents at the time of your original complaint or investigation.
- Examine the electronic health record to ascertain how each member of your medical team handled important information.
- Pay specific attention to documents such as lab results or doctors’ orders for suspicious addendums.
- Try to obtain records indirectly related to your care, such as administrative records, financial statements, and service records of staff that could indicate falsification of medical records due to inconsistencies.
- Watch out for undated records, illegible prescriptions, and unsigned reports.
- Maintain a complete medical history for your records including history and examination, assessment and treatment plan, operative notes, prescriptions, consent forms, referral papers, discharge summaries, and medical certificates.
- Once in litigation, seek a copy of the electronic medical audit.
- Choose a board-certified attorney with demonstrated expertise in the specialty area of medical malpractice.
What are the consequences of falsifying medical records?
Falsification of a medical record with any kind of alteration or destruction is considered as tampering with evidence in a medical malpractice case. This in itself is a cause of action permitting compensation to the plaintiff in most jurisdictions. A medical practitioner could lose their license to practice medicine if a court of law determines a tendency to falsify medical records. Healthcare providers may also lose accreditation, eligibility for federal reimbursement programs, and loss of trust if they are found to have falsified a patient’s medical record. Finally, knowingly falsifying medical records is a felony crime with a potential fine of $250,000 or five years in prison. In addition to compensating the victim, a court may order punitive damages to discourage falsification of medical records.