Avoid Temptation to Alter Patient Records

In the past few years I have seen a disturbing trend wherein we discover that our physician client has altered his or her records in some way after learning of a bad outcome or a lawsuit.

Records alteration is problematic to say the very least and can have very serious implications. This issue comes in many forms and can include adding information to the chart, removing information from the chart or even completely rewriting the chart. The common element of all records alteration is that it calls into question the reliability of the information contained in the records. It also does serious damage to the physician’s reputation. An opposing attorney is likely to suggest that the records alteration calls into question the physician’s veracity and that he or she is someone who should not be believed or trusted.

Many courts also have a separate cause of action for spoliation (destruction) of evidence. Some courts will allow the jury to be given an adverse inference instruction, which allows the jury to conclude that the evidence that was destroyed was not favorable to the person who destroyed it. The intentional destruction of evidence can also result in more severe sanctions including striking an answer.

If a physician’s licensing board learns that a physician has altered records, then it is likely to hand out a hefty sanction as well. Records alteration will likely be viewed as unprofessional conduct and result in some form of discipline from the licensing board. Depending upon the state disciplinary actions could be available online and be viewed by the general public. Having the public know that a physician altered records could cause a patient to seek care elsewhere.

There are very sophisticated tests that can be performed by certified forensic document examiners to identify records alteration that might not be visible to the naked eye. For instance, to the naked eye all of the black ink on a page might look the same, but under more specific examination it could reveal that more than one pen was used to make the entries suggesting a late modification/alteration to the records. If circumstances arise that warrant a late entry into a patient’s chart, then it should be designated as such.

Records alteration is a very serious issue with severe consequences, so physicians should not alter patient records under any circumstance.