Implications of Altered Medical Records
Complete, detailed and accurate medical documentation is not only essential for patient care but also for defense in the event of a malpractice lawsuit.
Every addition to patient records should be marked with the date and time that corresponds to the medical consultation or treatment being described. Any corrections should have their own date and time, with additional notes as needed to explain why the entry has been added later.
A health care professional who has been named in a lawsuit may feel tempted to make adjustments or additions to a patient’s records to make his or her role in the incident look less significant. Here is why it is never acceptable to tamper with or make alterations to medical records:
In many states, tampering with medical records is a criminal offense that leaves the perpetrator subject to fines or jail time. Even in instances where it is not technically illegal, proven records tampering could negatively affect a court case.
If you are found to have falsified medical records, you could be subject to discipline—including loss of your license—by your state licensing board.
If you are named in a medical malpractice claim that includes the accusation that you have altered medical records, it may adversely affect or even void your Professional Liability Insurance coverage and make it difficult or impossible for you to purchase another policy.
No matter the underlying circumstances of a patient incident, it is vital to maintain the integrity of patient records. Never let the fear of being found negligent override your duty to keep accurate medical records.