What's the verdict: A case of changing medical records

The case

A 45-year-old male patient presented to a community clinic in California. He was seen by a physician assistant (PA) who was informed by the patient that he was suffering from multiple myeloma with bone pain. He asked for pain control. Hydrocodone bitartrate 10 mg and acetaminophen 325 mg were prescribed. 

Over the next year the patient returned multiple times for refills of the opioids. His condition did not show anemia, weight loss, lytic lesions on x-ray, or clinical deterioration. 

The PA was suspicious of the diagnosis and confronted the patient, who admitted that he did not have multiple myeloma, but said he needed to receive continued refills of his opioids or might have withdrawal symptoms. 

Upon consultation with her supervising physician, it was determined that the patient could not receive opioids simply for the prevention of withdrawal and would need to be referred to an addiction medicine specialist. The patient found an attorney to review his case who asked for the medical records. Risk management at the affiliated hospital was informed and did not feel that there were any legal merits to a lawsuit because the PA took the patient’s history in good faith and could not have known that he was fabricating his history. 

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One year later the attorney representing the patient called the attorneys from the local hospital for a settlement conference. At first, the risk management team did not want to settle. However, the plaintiff’s attorney had called for the records a second time. During that time period, he noted that the PA had changed the records without dating the change. In fact, she had added information to the record with a similar pen to make it appear that the entries were made on the original date.

NEXT: The medical and legal sides

The medical side

After receiving the intent to sue, the PA in the above matter reviewed the records and felt that she should have included more details. Concerned about the ramifications of the lawsuit, the PA later documented key aspects of the history and physical exam that she had not included initially. She recognized that she should have documented her discussion about the risks of opioids and needed to document that she asked questions regarding the patient’s history of substance abuse. Although she may have asked these questions during the course of caring for the patient, initially she did not include them in her notes.

When she noticed this missing information, she used a similar pen to add the missing details. She did not date or sign the addendum and made the changes almost as if they were originally included in the record.

The legal side

After receiving the intent to sue, the PA in the above matter reviewed the records and felt that she should have included more details. Concerned about the ramifications of the lawsuit, the PA later documented key aspects of the history and physical exam that she had not included initially. She recognized that she should have documented her discussion about the risks of opioids and needed to document that she asked questions regarding the patient’s history of substance abuse. Although she may have asked these questions during the course of caring for the patient, initially she did not include them in her notes.

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When she noticed this missing information, she used a similar pen to add the missing details. She did not date or sign the addendum and made the changes almost as if they were originally included in the record.

NEXT: The verdict

The verdict

Despite the fact that the original lawsuit had no merit even with the incomplete record notations, because of California Penal Code Section 471.5 the case was settled for $1.5 million just for falsification of medical records.