Altered medical records can make it impossible to defend a medical liability case. Even additions and comments made by well-meaning physicians who are attempting to clarify or elaborate on previous notes can compromise the integrity of a medical record.
Plaintiffs' attorneys in medical liability cases routinely look for altered records, according to Texas Medical Liability Trust (TMLT). Remember, once you've finished a note, anything else is a late entry, regardless of whether you signed the note.
TMLT recommends you follow these guidelines to ensure a defensible medical record:
- Always date a late entry, and label it "LATE ENTRY."
- Explain the relationship of the late entry to a previous note, e.g., "addendum to note of 2/26/09" or "see 2/26/09 note."
- Explain the reason for the late entry. Why wasn't this information in the previous note? Enter the late entry in its normal chronological position in the chart, not squeezed into space near the previous note to which it relates.
- Avoid blank lines or large blank spaces in the medical record, as they can be an invitation to make changes or additions to a note.
Source: Texas Medical Liability Trust Risk Management Department. Writing in Stone: Alteration of medical records can prove fatal to malpractice defense. Texas Family Physician . 2001. Vol. 52 No. 2.
Content reviewed: 3/13/2007
TMA Practice E-tips main page