December 2003

Altering patient records

by Timothy J. Feuling

Whether you're called into court on a lawsuit, or into a meeting of the board of examiners about a complaint, you will probably be toting your patient case records with you. They could be the key to resolving any patient dispute.

They are so important, in fact, that many doctors carefully review the records ahead of time to make sure they are readable and correct. Unfortunately, some doctors are sometimes tempted to change the records slightly, adding details they forgot to put into the originals, "correcting" a few mistakes, or even rewriting the entire record because of bad handwriting.

Even if there is no intent to defraud, alternations are improper and should NEVER be made to records after the fact. This isn't only a rule for D.C.s ‑‑ it applies to every health care professional. The Nurses Protection Group, for instance, warns: "Altering the patient's records is the worst mistake you can make. By the time you receive a summons, the plaintiff's lawyer already has a copy of the hospital records. So if you try to alter them, any difference will be obvious later in court. Any alteration, however minor, is tantamount to an admission of guilt and will ruin your defense." ("Six Important Things To Do If You Get Sued," Nurses Protection News, Fall 1996)

Altering patient records is so serious that, in at least one case, a New Jersey medical doctor and his attorney were accused of violating the state's Racketeer Influenced and Corrupt Organizations (RICO) Act after allegedly rewriting records involved in several pending court cases. The defendants claimed they were merely re‑writing them because they were illegible but the plaintiff's attorney said the real issue was credibility.

What made the case even more complicated was the alleged involvement of the doctor's insurance company. According to the plaintiff's attorney, Glenn Bergenfield, the doctor's office manager testified that she and the doctor waited until all the patients and staff had gone home, and then rewrote the records.

"This astonishing revelation was not all," Bergenfield stated in his motion. "She claimed that the rewriting of the records (was) done at the insistence of the insurance company and the lawyer hired and paid by the insurance company... It appears that Princeton Insurance Co. and the lawyers they use to defend their insureds are encouraging at least one doctor to rewrite his records in order to improve their chances of winning. How likely is it that this disgraceful conduct is limited to this one doctor?" ("Rewritten Medical Records Prompt Rico Claim," New Jersey Law Journal, August 29, 1994)

The possibility that the insurance company or attorney advised the doctor to alter the records did not absolve him of wrongdoing and in fact may have led to the RICO charge (which involves two or more people who commit at least two illegal acts in concert).

In short, regardless of your motives or instructions or advice by your insurance company, attorney, or colleagues, never add, delete or change anything on a patient record once you become aware of the potential for litigation.

Of course, it's also vital that you keep proper original records, write clearly and legibly, and follow the other "rules" of record keeping. (For more information on this topic, see the article, "Tips for Better Record Keeping," at www.cbsmalpractice.com/report/articles/jul1101.htm)

Write ALL reports as though they could end up in court some day ‑‑ with your practice and reputation depending on them.

(Timothy J. Feuling is president of Chiropractic Benefit Services (CBS) and vice president of the World Chiropractic Alliance. He assists doctors in maximizing their practices through the proper choice of insurance and related services. Doctors may contact him with questions, comments, and requests for insurance quotes at 2950 N. Dobson Rd. Ste. 1, Chandler, AZ 85224, by phone at 800‑883‑0412 or by e‑mail: feuling@cbsmalpractice.com).