Never try to alter or "improve" the original record.
Q. I recently noticed a mistake I'd made in a patient's chart. What's the proper way to fix it?
Never try to alter or "improve" the original record. It's the easiest way to lose a malpractice suit, because alterations can easily be discovered by a plaintiff's attorney and used against you. No matter how pure your intentions were, he'll argue that you were trying to cover up what really happened. That will impeach your credibility, and turn the jury against you. Such record "tampering" can also lead to censure by the state medical board for professional misconduct, or denial of coverage by your malpractice insurer. In fact, many policies specifically exclude coverage when a physician alters his records.
A. No. Reviewing your records to check for accuracy and completeness is common and commendable-as long as it's done correctly. Adding a note such as yours shows that you were careful and concerned enough to add the missing information. However, the proper way to add missing information is to write the new note on a later entry, being sure to include the date of the addition.
Of course, you should never amend your records after an attorney has requested them or commenced litigation against you. The alteration will almost certainly be detected by comparing your records with those obtained from the hospital, clinic, or a referral specialist. If the case comes to trial, the plaintiff's attorney will point out the difference, which will seriously damage your defense.
Q. My hospital often calls to ask me to fill in a missing or incomplete discharge summary after the patient has left. Is there any problem with doing this?
A. Not necessarily. But first ask whether your hospital has a specific timeframe within which discharge notes must be completed. Some states require that such records be officially closed within a certain number of days after discharge. If it's consistent with hospital policy and state law, you may add to the record, noting that you weren't aware that the summary was incomplete at the time of discharge.
Again, never "backdate" such an entry. Use the date when you actually write the additional note. And here too, never write a new discharge entry if a lawsuit is pending, or if a plaintiff's attorney has requested the patient's records.
The author, who can be contacted at firstname.lastname@example.org
, is a healthcare attorney in Mt. Kisco, NY, specializing in risk management issues.
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