Doctors Altering Medical Records

surgery malpractice

When a medical mistake occurs, there is a temptation for doctors and other health care providers to change the medical records. It does not happen often because most doctors either believe they can defend the claim or would rather endure a potential medical malpractice claim than risking their medical license by altering a medical record. But that rationality is sometimes lost in the moment and the doctor ignores that it is wrong and against Maryland law because... well, you know why. There is no question that medical malpractice cases with great merit have been lost because a doctor altered a medical record that prevents the exposure to medical malpractice.

Conversely, a lot of doctor have altered medical records and got caught, often changing a difficult case into one that is indefensible. Thankfully, with the help of modern technology, it is easier to catch doctors who are trying to cover-up by altering the medical records. Today, forensic experts easily spot written alterations, often by finding changes in ink and writing pressure. Often, changes can be caught by Mylar transfer even when the same doctor makes a change with the same pen used in the original medical record.

Sometimes, it is even simpler than that because doctors are like everyone else: they get irrational during a cover-up. Often changes are made in the medical records when there is more than one copy of the patient's medical chart. Doctors are often unaware that copies have already been made and ad in their changes. Plaintiff's medical malpractice lawyers can easily cross check the records.

Today, modern technologies add a new twist. Computer files and storage drives often preserve old drafts and/or changes in the time of entry in ways that the doctor or health care provider making the change does not suspect.

The reality is that doctors almost invariably lose when the try this kind of cover up. They not only lose their license for altering the records they lose malpractice cases that would have been winnable for the doctor if they had only been honest. Why? Juries do not like liars and they don't believe anything they say.

Omission in the Medical Records

A lesser crime is omitting significant events from the medical records. Physicians do this all of the time. Sometimes, it is mere neglect or laziness. But in medical malpractice cases, it is often because the doctor is hiding something. We have a case now where the doctor operated on the wrong body part.

The doctor drilled into bone, put in a retractor to pull back nerves and tissues (ultimately damaging her radial nerve) before he realized he had confused left from right. The medical records do not make a single notation of this. At deposition, he claimed it was not important enough to note in the medical records. This woman was badly injured. I'm not sure the jury is going to like that answer.

Can a Doctor Makes Changes in Medical Records?

Doctors absolutely have the right - actually a duty - to change medical records that should be changed. The problem is not making changes; the problem is making changes to the record and pretending that the record was not changed after the fact.

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