When an individual undergoes medical treatment, the facilities, and providers who undertake their care are bound by law to maintain complete and accurate medical records.
Medical personnel is committing malpractice if they falsify or make unauthorized changes to those documents that are related to the treatment of the patient. This includes a person’s full medical history, treatment plans and medications that have been prescribed.
To prove malpractice, that individual must be able to show that the altered records led to an injury and that they have suffered either physically or monetarily as a result.
This could include being denied coverage or treatment by an insurance company as a result of the changes made, or additional costs incurred for treatments that were considered unnecessary. Simultaneous claims can be filed if these actions can include undergoing improper or harmful procedures.
Copies of Alerted Documents Are a Necessity
Proving the malpractice will require the patient making the claim to have copies of medical records. They have the right to review and make changes to them if they wish, but winning this type of case is heavily dependent upon the possession of the original records.
That’s because, through the use of modern technology, document examiners will be able to determine if records have been tampered with by doctors or other medical personnel. Chemical analysis of the document in question can be performed, which will show such things as ink differences and indentations on sheets from writing.
By obtaining copies of the altered documents, the patient will be able to show any changes to records definitively. Possessing the original papers and having written opinions from the pertinent medical personnel involved will aid in proving malpractice has been committed.
Determining Alterations and Proper Procedure
Things to look for when attempting to determine if a document has been altered are record inaccuracies, such as rewriting or changing the official record, the leaving out of facts significant to the claim, adding to another doctor’s notes or the simple destruction of the files in question.
When it comes to records destruction, determining who had access to the particular record will help narrow down the guilty party. Note additions also occur when doctors edit nurses’ notes or nurses write a colleague’s notes.
While copies of a medical record can be rewritten if it has been torn or soiled in some way, it must be explicitly stated on the page that it has been rewritten. In either case, the original copy should be kept with the record, regardless of the present condition.
Such corrections should be made in this manner: the original entry should be marked through with one line, and remain legible, with the entry date and initials of the person making them; the correction should make, dated and initialed; any additions should have the time of the entry and initials of the individual adding information.
Depending upon the state involved, there are specific procedures that must be followed when filing a claim of malpractice. The most significant of these regulations deals with whether the statute of limitations is still in effect for this claim.
If an individual has been injured because of this unauthorized and illegal action, seeking legal redress should be their next consideration. They will be able to determine there are enough facts on the side of the injured patient to pursue a case and explain what must be proved.