(Excerpted from Medical Economics, May 18, 2007)
In a perfect world, no one would get sued and no one would alter their records. And before a lawsuit if filed, most physicians would agree that they would never alter their patient records. They have been warned that altering records could have serious consequences. Many states have made it a criminal offense, as well as a basis for license revocation.
Unfortunately, some physicians faced with lawsuits or inquiries succumb to the temptation to rewrite chart entries. While these modifications may be nothing more than an honest effort to ensure that the records accurately depict what occurred, trial lawyers, juries or regulators, rarely view it that way.
Because it is very difficult to defend a malpractice case when a chart has been revised, many malpractice insurers will not defend – or pay claims for – physicians who have altered their medical records.
Do not fall into the trap that no one will ever know about the alterations. In one case, the plaintiff's attorney had a copy that the doctor's office had sent to another physician early in the treatment stages. That record did not match the record later given to the trial attorney during discovery.
Remember that document analysts have several low- and high-tech methods to determine if there has been tampering with written material.
The bottom line is that altering medical records, no matter how hones the intent, is not ethical. If you must alter a medical record, always follow the rules for doing so, including dating and initialing the revised entry.
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