Altering or even falsifying medical records is a dangerous crime with serious implications. With the emergence of electronic health records (EHRs), falsifying records is more difficult than ever. However, alteration and falsification are still active dangers, especially in issues of potential malpractice when doctors or other healthcare workers want to cover up negligence.
Alteration is more likely to occur than falsification, as it just requires changing parts of a record. However, this is still extremely uncommon as alteration of any kind is a crime — in some states, a felony — and doctors could lose their jobs and licenses. Furthermore, EHRs keep track of all changes in records and an altered record will also conflict with colleagues' copies and billing records. In larger institutions, where there are more people working on a case and more checks and balances, it is more unlikely to happen.
Doctors' malpractice insurers will often drop protection after evidence of tampering by the physician in question comes to light. Evidence of alteration or falsification will destroy a medical malpractice defense, as it illustrates that the physician knew there was something wrong in the care he provided.
Advice for Doctors
All updates for medical records are important. Not all falsification or alteration of medical records may seem so — such as saying a patient ate a meal when she didn't — but it is vital to be honest and ethical in all actions and notes on records. Plus, this kind of alteration could cause patient injury in the future, even if it hasn't so far.
You may know a colleague who is altering or falsifying health records. For example, sometimes physicians with drug addictions will falsify the records of drugs prescribed. They do this in order to support their habit — this is known as drug diversion. Whenever you know that a colleague is altering or falsifying health records, report them immediately and do not fill out their omissions — otherwise, you are an accessory and guilty of practicing unethical medicine.
Do You Need to Alter a Medical Record?
It is vital to note that not all alteration of medical records comes with foul intent. For instance, sometimes physicians or nurses need to add details they left out or correct misinformation in order to make sure a health record is complete. Doctors, if you need to do this there are a few actions you need to take:
- Make sure all corrections are easily viewable and have date and time stamps.
- Be aware of your state's laws regarding modification of patient health records.
- Note why you added the correction after the fact.
- It also will not hurt to have another doctor sign off on the correction a well.
In today's litigious malpractice culture when 75% of doctors in low-risk fields and 99% of doctors in high-risk specialties will be sued before age 65, it is essential to make sure you and all of your actions remain above board and transparent.