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Alteration of Medical Records

A common question that clients ask when pursuing a medical malpractice case is, “Will my doctor alter my medical record to hide the evidence?”

Detecting altered records was difficult 25 years ago.  Today, our lawyers have the ability to find inconsistencies in documentation and digital timestamps. Handwriting analysis can be an indicator and the ability to do that with AI has gotten much better in 2024.  Hospitals and medical institutions are increasingly using electronic health records (EHRs) with audit trails to reduce the risk of tampering.

Why Most Doctors Will Not Alter Medical Records

Though it seems like doctors and other healthcare providers accused of malpractice might simply change medical records to protect themselves, there are several reasons why doing so is not a good idea.  Tampering with medical records can have serious legal consequences for healthcare providers, including criminal charges, fines, and loss of medical license. In a legal context, altered records can be deemed fraudulent and may lead to more severe penalties or judgments in malpractice lawsuits.

First, falsifying a medical record is a crime punishable by a fine or even jail time. Additionally, altering medical records can make it harder for doctors to win medical malpractice cases.

Juries do not trust liars, and a questionable change to a record implies that something is being covered up. In other words, getting caught altering a medical record is worse than the consequences of telling the truth.

Secondly, it is hard to get away with falsifying medical records. Usually, documents are shared among doctors and nurses in medical settings, not to mention a patient’s health insurance provider and testing facilities.

Discrepancies can be spotted among different copies of a document and in a patient’s medical bills. With written records, forensic scientists can tell when a document has been changed by looking at inks and indentations in the paper. It’s also easy to track changes in electronic documents.

Doctors Still Do Alter Medical Records

Despite the risks, we still see altered medical records. Sometimes, when a healthcare provider is caught, complex cases suddenly become much easier to win. Conversely, cases with a lot of promise are sometimes lost because there is not an accurate record of what happened, preventing lawyers from being able to support their case with evidence.

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 mark what they are doing and do not obscure 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 after a short amount of time and a physician can distinctly remember 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 (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.

Doctor’s 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 instant process, so you are often asked questions about your health history when you go to a new facility.

Under the Health Insurance Portability and Accountability Act (HIPPA), 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 also can access medical records in certain situations. For more on accessing your medical records and how our lawyers can help, click here.

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 who 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 is pronounced dead. Her bowel had strangulated due to a severe hernia. Afterward, the toddler’s parents allege 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 finds in support of the plaintiff for $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.
One question that gets asked is can you sue a doctor for lying in the records?  You can sue a doctor for falsifying medical records but you need some actual harm to you to have a reasonable likelihood of a settlement or verdict.  There was underlying harm to the patient in all these examples of falsifying medical records.

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.

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