Never alter chart to help lawsuit
Everyone knows you should never alter medical records after the fact, right? But if it is so clear to everyone, why do medical malpractice defense attorneys repeat that rule like a mantra, and why do they all have plenty of anecdotes about defendants trying to improve the medical record?
Never assume that everyone knows not to do this, says Linda Stimmel, JD, partner and co-founder of Stewart & Stimmel LLP in Dallas. Specifically remind those involved not to change the record.
"I had a case one time where the physician involved was looking at his notes and saw they were not written as clearly as they could be, so he tore up his progress note sheet and wrote a new one. He didn't put anything in there that was false. He just wrote them in a better, more detailed manner," Stimmel says. "When that is revealed, the judge tells the jury that they can assume whatever the defendant destroyed was hurtful to them. That can kill you in court, even when you know that the change wasn't anything deceptive or false."
It is possible to add late entries to the medical record, Stimmel says, but they should be entirely transparent. Do not delete anything from the original, but rather add another entry and clearly note that it is a late entry and the date on which it was entered. Once a lawsuit is filed, however, Stimmel advises against even that type of clear addition to the record.
Dick Wiles, JD, an attorney with Hiersche Hayward in Dallas-Ft. Worth, notes that physical security of the chart is paramount. Keep it separate from any records of communications with plaintiff's counsel, he suggests. He also says that, aside from the legal and ethical reasons not to alter the chart, any such deception probably will be detected.
"You never know when someone else has a copy of that original chart. You may think you know, but you don't," he says. "I've seen cases in which patients got their hands on records that you just could never imagine they would have. It's unsettling, to say the least, when the plaintiff's copy looks different than the one you're holding."
Everyone knows you should never alter medical records after the fact, right? But if it is so clear to everyone, why do medical malpractice defense attorneys repeat that rule like a mantra, and why do they all have plenty of anecdotes about defendants trying to improve the medical record?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content