When physicians or facilities face medical malpractice lawsuits, there may be a tendency to alter the medical records to save oneself from the clutches of law. Tampered medical records are potential enough to change the course of any litigation. A thorough medical record review can bring to light any kind of such altercations in medical records.
Never think that altering medical records can occur in every medical malpractice case. Because falsifying a medical record is punishable crime. The wrong-doers can be fined, jailed or even prevented from continuing their medical practice. If the tampering of medical records is identified, they cannot even imagine winning their medical malpractice claims.
Even then some physicians may attempt altering the medical records. Even if an error was made in the record unknowingly, the doctor can be held accountable for the harm incurred by the patient from his negligence.
Medical records that are accurate and complete are essential not only for providing quality care and treatment in hospitals, but also for smooth legal proceedings. Key evidence indicating that a record has been altered in a lawsuit can force the settlement of a lawsuits with strong defendants.
Such incidents can make an easily winnable medical malpractice claim to be a very complex one to the defense or a complex litigation to an easy win for the plaintiffs.
Before delving deep into the consequences of medical record tampering and how medical record review can detect that, let’s know how medical record are important in malpractice lawsuits.
What exactly is a medical record?
A medical record is a summary of your medical history. Your primary care physician has a record of your medical history, but so does every other healthcare facility you’ve visited, from specialists to hospitals.
You have the option of authorizing the transfer of your medical records to another healthcare provider for continuity of care. Your medical records will not be consolidated otherwise. In recent years, there has been an effort to simplify the sharing of medical records between providers through digitization. Electronic health records (EHRs) are more easily shared and contain a summary of your health and treatment history.
Medical records must be kept on the premises in a secure location by doctors’ offices and hospitals. If the patients give them permission, they may share the medical records electronically with the other providers. This is not an automatic or instant process, which is why patients are frequently asked questions about their medical history when visiting a new provider or facility.
Patients have the right to a copy of their medical and billing records under the Health Insurance Portability and Accountability Act (HIPAA). Copying and mailing records are charged at facilities. They cannot, however, legally refuse the patient a copy if he has not paid their fee. It frequently takes several letters and phone calls to get the facility to send the records.
How vital are medical records in a medical malpractice litigation?
Medical records play a crucial role in medical malpractice litigation. Plaintiffs as well as defendants need medical records to prove their claims. Most importantly, the defendants have only medical records to prove their innocence if they haven’t done any mistakes. The plaintiffs may get other documents or medical records from other providers to prove their medical conditions and the cause of negligence.
Don’t think that physicians should not amend the medical records. If they had forgotten to make any entries, they can do it under the label, “addendum” or “late entry.” They have to give valid reasons for the correction done. Even if they strike the old entry, it should be legible for the readers.
Sometimes, even including what is unknowingly omitted can become illegal if that was done too late. Because people tend forget the details of the happenings after a few days. Therefore, if they have to add the missed data, it should be done within the same day.
Correcting the poor documentation or the already noted wrong diagnosis, treatment decisions, unnecessary diagnostic studies, or surgery suggestions would end up in serious consequences. Because, all the follow-up treatments would have been done depending on the wrongly documented record. If the diagnosis was wrong, then all the follow-up also would have added more harm to the patient.
Trying to alter the first wrong document cannot solve the issue but make the provider or facility that did the mistake in hot water. All other documents stand as solid proof not only for his wrong diagnosis and treatment but also to his falsification of medical records.
Jurors will not leave the liars without being punished. Even if the wrongdoers accept their mistake, they could get escape with minimum, moderate or severe punishments depending on the harm done to the patient. However, if the tampering of medical record is proved, they have to face severe punishments than what they will get for the wrongdoing. Jail time or cancellation of their licenses would be the result.
Types of medical records where such corrections may be needed are listed as follows:
- Personal Particulars
- Medical History of the Family (high blood pressure, anxiety, etc.)
- Medical History (previous illnesses/complaints, pregnancies, immunizations, use of recreational drugs, allergies, and so on)
- Referrals
- Examination and imaging reports
- Medication and Treatment History
- Medical Directives (the wishes of a patient regarding their medical care if they become unresponsive)
- Autopsy Findings/Death Certificate
How can medical record review unearth medical record tampering?
Attorneys can easily find out such inconsistencies found in the different copies of a document as well as in a patient’s medical bills. Forensic scientists can say when a document has been altered by inspecting the inks and indentations in the paper. It’s also simple to keep track of changes in electronic documents.
However, by analyzing different documents, medical record reviewers can easily identify such medical record altercations or inconsistencies. With regard to electronic medical records, nowadays, all the providers of a patient can share the same medical documents easily via digital mediums.
Therefore, there would be different copies of the same medical records with different providers. When a medical provider makes the changes in the records he has, he may not be able to do the same with the same records already shared with other providers. When all of these copies are compared, while medical record review, the reviewer can identify the falsification.
This becomes easy as the medical record review companies get multiple copies of the same medical records from different providers to be reviewed. While extracting the duplicate copies, the reviewer gets the chance to locate the inconsistencies. Each and every inconsistency will be notified to the attorney along with the review reports.
Even the number of records missing can be located and pointed out clearly for the attorney to request the defendants to produce the missing documents. Therefore, even if the provider had removed a particular document in full, he could not escape the careful scrutiny of a medical record reviewer.
Usually, the medical record reviewers would
- Spot any discrepancies in the records
- Pinpoint any instances of carelessness
- Accurately timeline the occurrences
- Give deposition questions
- Identify the inconsistencies even in the deposition testimonies of medical providers
- Point up any false or misleading information
Why medical record review should be outsourced in medical malpractice claims?
Working through complex medical aspects and understanding medical terminology will be a time-consuming process for the attorney. The last thing an attorney needs, especially in complex cases, is to evaluate and correlate medical terms with the personal injury case.
Fortunately, with the assistance of a medical record review service, these lengthy manual hours can be easily reduced. Companies provide medical records review professionals who convert voluminous data into readable and easy summarization that is chronologically organized.
This accessibility allows both attorneys and medical professionals to focus on their core responsibilities rather than spending time analyzing large amounts of data.
As we have seen earlier, identifying the falsification involves more time than simply reviewing the medical records. This would consume most of the litigator’s time from being involved in the other significant proceedings. Even with an in-house review time, the attorneys have to face more billable hours to their employees and more expenses.
Medical record reviewers who are doing these kinds of work with efficiency can accomplish the task within no time. Even a huge volume of data can be processed and summarized into intelligible formats with accurate medical data.
Even the medical record reviews could save the defense medical practitioners if they did not do any falsification. The efficient medical record reviewer can be able to prove from the medical records that the corrections done on the records are not illegal but valid ones with supporting documents.
To summarize, missing medical records or falsification of medical records can be pivotal in deciding the destiny of any medical malpractice lawsuit. Some of those altered or missing records can be beneficial in proving liability or negligence, or even innocence.
A comprehensive medical record review can identify missing as well as altered medical records and efficiently point out the inconsistencies to win complicated litigation.
