As a medical malpractice lawyer, the issue of falsified medical records arises in two different contexts. The first context is the falsification of medical records in order to hide negligent care or intentional abuse or neglect. The destruction, hiding or alteration of evidence is sometimes referred to as “spoliation.” Different states treat spoliation in different ways. Generally, spoliation is frowned upon by the law, as you can imagine. In some states, it forms the basis for an award of punitive damages against the offending party. Here is how punitive damages work: if a wrongdoer causes harm to a patient through negligent or reckless misconduct, the patient is entitled to compensatory damages to make up for his or her harms and losses, including lost wages, medical expenses and pain-and-suffering. When punitive damages are permitted, the injured party is entitled to an additional award of money meant solely to punish the wrongdoer in addition to compensatory damages.
In a medical malpractice lawsuit, evidence of an altered medical record is powerful circumstantial evidence of wrongdoing. There is no reason to erase, change or misrepresent information in a medical record other than to hide the truth. In the age of electronic medical records, finding proof of alteration is at once easier and harder. It is easier in the sense that each entry in the medical record creates a log entry reflecting the identity of the person who accessed the medical record, the date and time of the access, the portion of the medical record that was accessed and the changes that were made. On the other hand, it would be physically impossible to review an entire medical record through the eyes of the audit trail. At best, the audit trail can be used to access a few key portions of the medical record to determine their integrity. Under the old system, when paper records were generated, it was easy to see when an entry had been modified through the use of interlineation, white out entries using different colored ink and so on.
The second context in which falsified medical records become important is when a patient discovers that information contained in their medical record is inaccurate. In some instances, the patient may suspect that their physician, nurse practitioner or nurse entered inaccurate information on purpose. In other situations, inaccurate information may be added to a medical record by a negligent care provider who either failed to listen to what the patient was telling them or misrepresented information through carelessness.
When a patient’s medical record is inaccurate, HIPAA regulations provide a process by which a patient can request that a medical provider correct their record in order to make it accurate. Generally, careless, inaccurate entries do not pose any problem. However, in some situations, the absence of the word “no” or inaccurate entries pertaining to drug or alcohol abuse, psychiatric conditions or the way in which an accident happened can have a profound impact on civil litigation. In these instances, you will need to have your personal injury lawyer guide you on the steps necessary to correct the inaccurate record. Contact a personal injury lawyer at a firm like Mishkind Kulwicki Law Co., L.P.A. today.