Medical Malpractice
A common question clients ask when pursuing a medical malpractice case is, “Will my doctor alter my medical record to hide the evidence?” It is an understandable concern. Medical records are the foundation of any malpractice lawsuit, and if they are altered, falsified, or destroyed, patients worry that the truth may never come out.
Twenty-five years ago, detecting altered medical records was extremely difficult. Today, lawyers have powerful tools to uncover inconsistencies. Digital timestamps, metadata, and audit trails within electronic health records often reveal when changes were made and by whom. Handwriting analysis still plays a role in paper records, and advances in artificial intelligence have made spotting falsification more accurate. Hospitals now rely heavily on electronic health records with audit trails that reduce the risk of tampering, although problems still occur.
Most doctors will not falsify records because the consequences are severe. Altering a patient’s chart can bring criminal charges, heavy fines, loss of medical license, and devastating results in a malpractice trial. Juries are far less likely to believe a doctor who has been caught changing records. In fact, once falsification is proven, a case that was once complex often becomes much easier to win. That is why understanding how altered records are discovered and used in court is so important for malpractice victims.
Why Most Doctors Will Not Alter Medical Records
Although it may seem that doctors or other healthcare providers accused of malpractice might simply alter medical records to protect themselves, there are strong reasons why most will not take that risk.
Falsifying or tampering with medical records can carry serious legal consequences, including criminal charges, substantial fines, and the permanent loss of a medical license. In malpractice litigation, altered or falsified records are often treated as fraudulent, which can lead to harsher judgments and greater liability in a lawsuit.
First, falsifying a medical record is a crime under both Maryland law and federal law. A provider who is caught can face fines, jail time, and professional discipline. In addition, altering medical records almost always makes it more difficult for a doctor or hospital to defend a malpractice case. Juries tend to view altered records as an admission of guilt, and once credibility is gone, it is nearly impossible for the defense to recover. Getting caught changing a chart is almost always worse than facing the allegations of malpractice themselves.
Second, it is very difficult to conceal a falsified medical record in modern practice. Patient records are shared among doctors, nurses, insurance companies, and outside testing facilities. Any alteration can be compared across versions, and discrepancies often stand out. With written records, forensic experts can identify changes by analyzing ink, handwriting, and paper impressions. With electronic health records, audit trails and timestamps make it simple to see when entries were added, deleted, or modified.
A doctor who lies in medical records is committing one of the most serious mistakes possible. It is illegal, destroys trust, and can dramatically alter the value of a malpractice lawsuit. This is why it is, thankfully, rare.
True corrections must be dated and signed. Quiet changes or backdating entries can be treated as falsification and fraud.
Doctors Still Do Alter Medical Records
Despite the serious risks, our malpractice lawyers still encounter cases involving altered medical records. In some lawsuits, providers have added late entries, deleted unfavorable notes, or created duplicate records in an attempt to cover their mistakes. When these changes are uncovered, what began as a complicated malpractice case can suddenly become much easier to prove. Juries see altered or falsified records as powerful evidence that negligence occurred, and the credibility of the defense often collapses.
On the other hand, promising malpractice cases can be undermined when records are missing, incomplete, or inaccurate. Without a reliable account of what actually happened, it becomes more challenging to prove causation or establish the timeline of events. This is why altered medical records can swing a case in either direction: they can create devastating evidence for the plaintiff when tampering is exposed, or they can strip away critical proof if the alteration conceals key facts.
Altering medical records is not only illegal, it is one of the most damaging acts a healthcare provider can commit in litigation. It can transform the outcome of a case, either by handing a jury proof of dishonesty or by depriving the patient of the very evidence needed to hold the provider accountable.
Is It Illegal to Alter Medical Records?
Altering a medical record is a crime and can be used against doctors in medical malpractice cases. However, it is not illegal for medical professionals to make honest updates to records, as long as they properly document their actions and do not obscure any existing information. There are legal and regulatory frameworks in place to deter such practices. The Health Insurance Portability and Accountability Act (HIPAA), for instance, sets standards for protecting and handling medical records.
To correct a mistake, doctors should make a new note with the current date and time. The note should be labeled “Late Entry,” “Correction,” or “Addendum.”
They should explain the relationship of the note to a previous one, including the reason for the error, and the source of the new information. Records should always reflect who did what. Finally, they should draw a line through the incorrect entry—the text, however, should still be legible.
If an omission in a medical record is noticed within a short period and a physician can distinctly recall administering medication or other treatment, a late entry should be made.
However, if a day or more has passed, it is unlikely that the physician can reliably remember precisely what happened. Filling in missing information after the fact may lead to a misrepresentation of events. As such, filling in omissions may also be an illegal act.
According to Maryland law, a healthcare provider who knowingly or willfully destroys, alters, or otherwise obscures a medical record or other information about a patient to conceal evidence is guilty of a misdemeanor and is subject to a fine of up to $5,000 and/or imprisonment up to one year. They will also lose their medical license.
What Is a Medical Record?
A medical record is a summary of your health history. Your primary care physician has a medical record for you, but so does every other healthcare facility you have used, from specialists to hospitals.
You can authorize that your medical records be sent to another healthcare provider for continuity of care. Otherwise, your medical records will not be consolidated. In recent years, there has been an effort to simplify the sharing of medical records between providers through digitization. Electronic health records (EHRs) summarize your health and treatment history and can be shared more easily.
However, there is still no standard nationwide software or process for medical professionals to share information. This means that you may have to put in multiple requests if you want a complete copy of your medical record.
Your medical record includes:
- Personal Information (name, SSN, etc.)
- Family Medical History (risk of high blood pressure, anxiety, etc.)
- Medical History (medical conditions, past illnesses/complaints, pregnancies, immunizations, recreational drug use, allergies, etc.)
- Referrals
- Examination Results (physicals, x-rays, lab reports, scans, etc.)
- Medication and Treatment History (drugs used, the possibility of drug interaction, success/failure of past treatments, past surgeries, etc.)
- Medical Directives (the patient’s wishes about their medical care if they become unresponsive)
- Autopsy Report/Death Certificate
Who Can Access My Medical Record and Where Is It Kept?
Although patients have the right to access a copy of their medical records, original documents belong to the healthcare facility that created them.
Doctors’ offices and hospitals must keep medical records on the premises in a secure location. If you grant permission, they may share your records electronically with your other providers. However, this is not an automatic or instantaneous process, so you are often asked questions about your health history when you visit a new facility.
Under the Health Insurance Portability and Accountability Act (HIPAA), patients can receive a copy of their medical and billing records. Facilities do charge a fee for copying and mailing records. However, they cannot legally deny you a copy because you have not paid their fee. Getting the facility to send the records often takes multiple letters and calls.
In a lawsuit, medical records are essential evidence. Insurance providers can review your records and request a copy if you file a lawsuit. A patient’s personal representative can also collect their medical records, which is especially useful in wrongful death cases.
The government and law enforcement can also access medical records in certain situations. For more on accessing your medical records and how our lawyers can help, click here.
What Happens When a Doctor Lies in Medical Records?
When a doctor lies in medical records, the consequences can be severe both legally and professionally. In malpractice litigation, juries tend to view lies as worse than the underlying mistake. A false entry or altered chart can be treated as fraudulent, making it much easier for a plaintiff to prove liability. In one case we talk about below, a weak case turned into a $1.5 million settlement because the doctor tried to falsify the records.
Beyond the lawsuit itself, lying in records can expose a doctor to criminal charges, fines, and disciplinary action by the state medical board. The result is often career-ending. For patients, the discovery of a lie can change the entire trajectory of a case, turning what was once a contested claim into one where the jury is quick to side with the victim.
Audit trails, metadata, and handwriting analysis expose hidden edits. Cross-checking outside records often reveals lies.
Can You Sue for Inaccurate Medical Records?
Yes and no. You can bring a lawsuit if inaccurate medical records cause you harm, but the inaccuracy itself is not enough. Courts generally require proof that the false or incorrect record led directly to an injury.
For example, if an inaccurate entry about your allergies results in you receiving the wrong medication and suffering a serious reaction, you may have grounds for a malpractice lawsuit. On the other hand, if your chart contains small errors that do not affect your treatment, you probably do not have a claim worth pursuing. The key issue is whether the inaccuracy caused actual injury or contributed to a preventable outcome.
Altered Medical Record Verdicts and Settlement Amounts
The following verdicts and settlements are examples of lawsuits that involve examples of falsifying medical records. Your case will not necessarily look like these cases. The settlement value of a case, for example, depends mainly on the type of injury you or a loved one suffered. Our lawyers have compiled information on the value of cases by injury type.
- 2023, Florida: $4,000,000 Settlement In this case, the lawyers allegedly altered the medical records. A 35-year-old man died of a heart attack in the emergency room. The crux of the lawsuit was the alleged misdiagnosis of the man. A critical point in the case was a handwritten note in the medical records. The note, which appeared almost a year after his death, altered the original ER records from “Chest Pain NOT Resolved” to “Chest Pain NOW Resolved.” This change was significant as it potentially weakened the plaintiff’s case by suggesting his condition had improved. After extensive depositions and discovery processes, it was alleged that the defense counsel’s office was responsible for the alteration. This led to a $ million settlement.
- 2022, South Carolina: $2,000,000 Verdict A woman sued a dentist alleging that he negligently extracted 16 teeth instead of the three teeth that were required, that 13 of the teeth extracted were in good condition and did not need to be removed, and that he failed to provide the proper standard of care. The plaintiff also contended that the defendants changed her medical records to conceal their mistake.
- 2021, California: $381,600 Verdict In this case, a doctor and hospital were held liable under California law for accessing and disclosing a patient’s medical records without proper authorization. The plaintiff sued the defendants for disclosure of medical information and sued the defendant’s hospital for negligent misrepresentation of fact after his records were allegedly accessed improperly. The verdict included $150,000 for pain and suffering.
- 2020, Kentucky: $5,000,000 Verdict A nursing home admitted an 85-year-old woman. Its staff designated her as a choking risk and ordered a soft diet. Despite the order, they fed her a regular one. Four months into her stay, the woman experienced two choking incidents within 24 hours. The first involved a strawberry, while the second involved a tomato. Three months later, she choked on an unknown food item. The nursing home staff found her unresponsive. After they unsuccessfully performed the Heimlich maneuver, the woman died. Her family alleged that the nursing home staff’s failure to manage her choking risk caused her death. They also alleged that they posthumously altered her medical records by omitting the fatal choking event. The family’s forensic document expert concurred. The nursing home denied all allegations. It argued that her advanced age and co-morbidities caused a natural death. Those arguments failed, obviously. Juries do not like doctors who lie, and that was likely important in this verdict.
- 2019, Pennsylvania: $3,380,000 Verdict A toddler is taken to the pediatrician for vomiting. The pediatrician prescribes nausea medication, and the family goes home. That night, the toddler becomes unresponsive, and her parents take her to the ER. Early the following day, the toddler tragically dies. Her bowel had strangulated due to a severe hernia. Afterward, the toddler’s parents alleged that the hospital did not take her symptoms seriously. She had been vomiting bile, they claim, an indicator of bowel obstruction and a surgical emergency. Given the vomiting, doctors should have ordered testing that would have revealed the obstructed bowel in time to save their daughter’s life. It was also discovered that “bilious vomiting” was written on the girl’s medical record but was later removed. The hospital claims that the entry was written by mistake and that the girl was already too far gone to save when she came into the hospital. However, the court grants the parent’s motion for an adverse inference charge due to the illegally altered medical record. In other words, the fact that the hospital felt compelled to alter the medical record indicated that it must have contained unfavorable information. A jury awards the plaintiff $3.4 million.
- 2018, Texas: $7,635,000 Verdict A 14-year-old girl commits suicide shortly after her pediatrician prescribes an antidepressant to treat her depression. Her parents allege that the pediatrician should not have prescribed the drug since antidepressants increase the risk of suicide in children and teens. Furthermore, they say the pediatrician did not warn them of this risk. When the mother requests medical records from the pediatrician’s office, she discovers that the defendant pediatrician altered her daughter’s records, resulting in two different sets. The doctor lied to protect himself from a malpractice lawsuit. It is surprising how often doctors get caught in a lie because they don’t make sure all sets of records have been altered. After a lengthy trial, a jury awards the parents more than $7 million.
- 2018, West Virginia: $5,500,000 Verdict A 75-year-old man is taken into intensive care complaining of trouble breathing. Doctors place two tubes. An endotracheal tube helps him breathe, and a nasogastric tube, which passes from the nose into the stomach, allows doctors to give him food and medicine. While doctors are placing the nasogastric tube, the endotracheal tube is dislodged. A respiratory therapist is paged and replaces the tube incorrectly. The man’s oxygen level and heart rate begin to drop. Respiratory staff begin CPR, and another doctor from the ER is called. She notes the incorrect placement of the breathing tube and makes a correction. However, they are unable to resuscitate the man, and he is pronounced dead. A jury awards $5.5 million to the man, who is survived by his wife.
- 2015, California: $1,500,000 Settlement A 45-year-old man visited a community clinic complaining of bone pain and claimed to be suffering from multiple myeloma. A physician assistant (PA) prescribed hydrocodone and acetaminophen for pain relief, and over the next year the patient returned multiple times seeking refills. Eventually, the PA grew suspicious when the patient showed no clinical signs of cancer. After being confronted, the patient admitted he did not have multiple myeloma and simply wanted continued access to opioids. The PA and supervising physician refused further prescriptions and referred the man to addiction medicine. When the patient’s lawyer later requested medical records, it was discovered that the PA had gone back and changed entries without properly documenting or dating the corrections. She used a similar pen to make the alterations appear original. Under California Penal Code Section 471.5, falsifying medical records is itself an actionable offense, and despite the underlying malpractice claim arguably lacking merit, the case was ultimately settled for $1.5 million based solely on the record tampering.
Contact Our Malpractice Lawyers
If you believe you have been a victim of medical negligence, tell us about your case. Our experienced lawyers handle severe medical malpractice cases and may be able to help you win a settlement.
Keep in mind, we are medical malpractice lawyers, not doctor-altered medical records lawyers. It is awful when a doctor alters medical records, and there are actions that can and should be taken against that doctor. But our firm only handles catastrophic injury and wrongful death malpractice lawsuits.
Information for Medical Malpractice Victims
- Overview of medical malpractice cases
- Frequently asked questions
- What level of compensation can I expect?