Falsified Medical Records

Pennsylvania Medical Negligence Lawyer

Physicians are supposed to doctor patients, but they are not supposed to “doctor” records. Unfortunately, however, falsified records are something we see from time to time in handling medical malpractice cases, although it is getting more difficult for the doctor to get away with that sort of bad behavior.

We Have Seen Many “Doctored” Medical Records

In the decades we have been handling medical malpractice cases, we have seen all sorts of “doctored” records. One of our most vivid memories is a lung cancer case that occurred in Erie. The critical issue in the case was who was at fault for the fact that a CT scan had not been done on a middle-aged man who had a chest X-ray, which was suspicious for lung cancer: Was it the doctor for never ordering the CT scan, or was it the patient for not showing up for the test? The doctor claimed that he ordered the CT scan and told the patient when to get it done, and in support of his argument he produced a copy of his office records showing that the patient had been given an order for a chest X-ray.

Our client vehemently denied that had ever occurred. When we told him and his wife that we had a copy of the doctor’s records, which showed that the husband had been advised to get a CT scan, the wife immediately spoke up and said, “Well, that is not what my copy of the records shows.” It turns out that a year before we ever filed a lawsuit, the wife happened to stop by the doctor’s office to pick up a copy of her husband’s records for an unrelated Social Security case and indeed they showed exactly what she said: The doctor had never ordered a CT scan or said anything about it to her husband! Apparently, after the lawsuit was filed and the doctor realized that the failure to order the scan was an obvious mistake, he went back and “doctored” the record to make it appear as if he had ordered the CT scan. Little did he know (or remember) that the wife had a copy of the records in their original form. We had him cold, and as you might imagine, that case never saw the light of day in a courtroom.

Changing Medical Records Can Hurt The Doctor In Front Of A Jury

We have had other situations where doctors change times of critical events, make late entries in a hospital chart and many other things. Almost in every case, it comes back to haunt them because any situation where a doctor has changed records it is absolutely “toxic” in front of a jury. People can understand a doctor making a mistake but they cannot understand or forgive him or her for being dishonest.

Electronic Medical Records Make Falsifying Records More Difficult

In recent years, it has become more difficult for a doctor to change records, particularly hospital records. In the “old days” hospital charts consisted mainly of hand written notes by nurses and physicians, and unless you wanted to hire a handwriting expert, it would be difficult to prove that someone made a late entry. Even if you did have a handwriting expert to say that, the hospital would get a different handwriting expert to dispute it. Now, however, the majority of hospital charts are in electronic format and the software is required by federal law to maintain an “audit trail,” which tracks activity in the chart. Every doctor and nurse has a personal ID number that he or she must input to gain access to the computer. Thus, the audit trail will tell you who was in the record, when they were there, and what they did. One of the problems we have, however, is that the hospitals are often reluctant to voluntarily release this audit trail information without a judge forcing them to do so.

As for records in a doctor’s private office, many of those are still kept in handwritten form and, therefore, the safeguards of the audit trail may not apply.

Medical Records Should Never Be Falsified

In the end, whether the records are electronic or handwritten, physicians should think twice before they “doctor” something other than the patient because an industrious lawyer working on behalf of the plaintiff will invariably discover their shenanigans, and it will come back to harm the doctor even if his or her medical care in the case was not that bad.

Free Medical Malpractice Case Evaluation

If you or a loved one is the victim of medical malpractice, please contact us today for a free case evaluation at 412-281-2200. We have helped hundreds of families get the justice they deserve. There is never an out-of-pocket fee to our clients.