Importance of Good Medical Record Keeping

Medical records play a crucial role in professional healthcare practice and the provision of high-quality healthcare services. Medical records are also used as evidence in medical-legal cases. They act as valuable documents to audit the standard of healthcare services provided and also can be used for patient complaints, investigating serious incidents, and compensation cases.

Regardless of the format of the records, whether paper or electronic, good medical record-keeping allows for patient continuity and improves communication among healthcare practitioners. Medical records should be periodically updated by all members of the multidisciplinary healthcare team involved in a patient’s care.

Structure of Standard Medical Records

The structured information which needs to be included in the medical records include:

  • Demographics of the patient
  • Reasons for visit
  • Details of present illness
  • Past medical/surgical/social/family histories
  • Details of allergies
  • Review of symptoms
  • Positive exam findings
  • Pertinent negative exam findings
  • Key abnormal diagnostic findings
  • Diagnosis or impression
  • Management plan and agreed actions
  • Treatment details and future treatment recommendations
  • Medications administered, prescribed or renewed
  • Instructions and/or educational information given to the patient
  • Clear documentation and justification for any patient care
  • Documentation of communication with the patient and family, physician to physician
  • Recommended return visit date

Best Practices in Documenting Medical Records

  • Always use timed entries
  • Make the entries legible
  • Limit the usage of abbreviations/shorthands
  • Make objective comments
  • Avoid personal comments
  • Document any noncompliance of treatment if any
  • Document even oral communications and actions taken
  • Never delete or alter the contents of clinical notes
  • Document informed consent

Importance of Accuracy and Legibility in Medical Records

Medical records represent the formal documentation of a physician and it must be clear, accurate, legible and written in a scientific manner. As per the medical malpractice law, if a medical decision, treatment or procedure is not recorded in the medical record, then it has not been performed. Thus, in a court of law, it does not matter if the healthcare provider has done the best for the patient unless they have accurately documented the fact. However, the legal burden of proof can depend on the specific setting and circumstances in which the notes are being scrutinized. Consequences of incomplete medical records could be hefty in a personal injury lawsuit.

Falsification of Medical Records

In some cases, the medical chart is ambiguous, fragmentary, or incorrect. Unless the healthcare provider is confronted with a patient complaint, a professional misconduct inquiry, or a lawsuit, they may not understand the flaws in their paperwork. In such instances, there may be a temptation to “clarify” what happened in the medical record, eliminate potentially damaging information, or even establish an entirely new record. This is called Falsification of Medical Records.

In a medical malpractice case, falsification of a medical record with any alteration or destruction of the original data is deemed tampering with evidence. In most jurisdiction, this is a cause of action that allows the plaintiff to get compensation.

A medical practitioner may lose his/her license to practice medicine if the court identifies a tendency to falsify any component of medical records. Healthcare providers may also lose eligibility for federal reimbursement programs, accreditation, and trust if found to have falsified a patient’s medical record.

Why do healthcare providers tamper the medical records?

Medical record tampering may be done under the below-mentioned circumstances.

Intention to commit a fraud – This includes billing for services not rendered or doing deliberate billing errors.

Notification of litigation – The healthcare provider may not realize the fact that the patient and their attorney already possess the records.

Fear of being exposed by destructive information – When a diagnosis is missed, or a bad outcome occurs, the guilt associated with this may provoke the healthcare provider to review the original medical records and add information to them.

Legal Consequences of Medical Record Tampering

The aftermaths of medical record tampering is not only confined to suspension or cancellation of the license of the physician or the healthcare professional. Depending upon the circumstances of nature and effects of falsification, medical record tampering could end up as a felony crime with a potential fine and imprisonment. Aside from the legal obligations to recompense the affected patient, the   defendant may also be liable for punitive damages.

The penalties and legal consequences of medical record tampering may differ from state to state. In Maryland, purposeful medical record tampering is considered a misdemeanor, ending up in a fine of up to $5,000 and/or imprisonment up to one year.

Let me give you an example of a lawsuit involving medical record tampering.

A toddler was suffering from severe vomiting and was taken to the pediatrician. The pediatrician prescribed some medications for nausea and sent the child home. The child was reported to the ER as she became unresponsive. Despite the treatment at the ER, the child was dead, and further investigation revealed serious bowel obstruction caused by a severe hernia.
The child’s parents claimed that the physician did not consider bile vomiting as a bowel obstruction symptom, and no investigation was ordered. There was a record of “bilious vomiting” in the medical chart, which was later found to be removed.
The hospital denied the allegation, stating that it was found to be a wrong entry and was removed from the chart. However, the jury identified the correction in the chart as medical record tampering. The plaintiff was awarded a compensation of $3.4 million.

When Should an Attorney be Alert on Medical Record Tampering?

  • When the attorney find conflicts with the documentation in medical records.
  • When a healthcare provider learns that the plaintiff’s attorney is seeking a copy of the medical record.
  • When the plaintiff attorney gets to know the medical record is incomplete or missing.
  • When the result of the injury is not consistent with the documentation in medical records.
  • When there is little or no documentation about an event or incident that resulted in harm to the plaintiff.
  • When the plaintiff’s subjective complaints are consistent with the missing information.
  • When there is a delay or issues in obtaining medical records from the practitioner.
  • When there is too good to be true documentation such as perfectly stable vital signs or weight which does not vary from one to another.
  • When an unexpected event has occurred, such as an injury, fracture, birth injury, surgical error, death, burn, or whenever there is a medical catastrophe.
  • When a hospital-acquired medical condition develops such as pressure sore, retained sponge, air embolism, and so on.

Final Thoughts

Medical record alteration, without good cause and proper authentication may be done to hide the consequences of medical malpractice. Medical records that are illegible, undated, incomplete, or inaccurate are often employed by a plaintiff to cast doubt upon the standard of care the patient received from the healthcare provider. It is considered as a serious offense in medical malpractice claims.

Altering any part of the medical record implies tampering with the evidence. Such evidence will undermine the defendant’s credibility in front of a jury and give the impression that they are attempting to conceal the truth. Evidence that the medical records have been tampered with can require an otherwise viable case to be settled.

At LezDo techmed, we support medical malpractice attorneys with our medical record review services. We scrutinize the medical records for any potential tampering or falsification. We analyze the records to identify missing records which carries relevant information related to the injury or claim.