Tampering with Medical Records

Red Flags for Tampering with Medical Records

What are the red flag warning signs that someone may have been tampering with medical records? Be suspicious when:

• the result of the injury is not consistent with the documentation;
• the plaintiff’s complaints are consistent with the missing information;
• there is a delay in or an inability to obtain medical records;
• there is too good to be true documentation such as perfectly stable weights or vital signs which do not vary;
• a provider learns that a plaintiff’s attorney is seeking a copy of the medical record;
• the plaintiff’s story is different or conflicts with the documentation;
• the medical record is missing or incomplete;
• there is little or no documentation about an event or incident that resulted in harm to the plaintiff;
• an unexpected event has occurred, such as an escape from a healthcare facility, an injury, fracture, birth injury, surgical error, death, burn, or whenever there is a medical catastrophe;
• a hospital acquired condition develops such as a stage III or IV pressure sore, air embolism, retained sponge, and so on.

Responsibility for Preserving Medical Records

What are the responsibilities of facilities for maintaining records?

“The health records of patients involved in potentially compensable events and claims should be completed as soon as possible after the patients are discharged. The primary and secondary records should then be copied for use by the risk manager and the originals secured in a locked storage place. Any written incident reports, investigative reports, peer review records, and credentialing files relevant to the case also should be protected.

State laws and findings in past legal cases dictate what kinds of information must be provided to the parties in a lawsuit, and risk managers should maintain the confidentiality of sensitive documents until it is determined exactly what kinds of information must be turned over to the injured party’s representative. Patients and their legal representatives have automatic access to the patient’s health records, and so copies of internal incident reports must not be placed in health records.”

The Joint Commission, state and federal regulations address the need to maintain accurate and complete records. Nurses and physicians can be disciplined by their boards of licensure for documentation errors, lose insurance coverage, or be charged with a crime. The stakes are high.

Why Do Healthcare Providers Alter Records?

Why do healthcare professionals get involved in tampering with medical records? There are many reasons why a person would tamper with records. Here are some motivations:

• an intention to commit fraud, such as billing for services not performed
• fear or guilt when an untoward outcome occurs
• fear of being exposed or harmed by damaging information
• desire to cover up a mistake when notified of being sued

Any additions or deletions to records will be detected if the attorney requests a second set later in the litigation. Many of our plaintiff attorney clients make this a practice and some have been amazed by what they’ve discovered.

It is imperative that you understand how you can participate in the detection of tampering with medical records.

Pat Iyer MSN RN LNCC is president of The Pat Iyer group. She presented a webinar specifically geared to teaching LNCs how to detect altered medical records. Learn about Fraudulent Medical Records at this link.

See Roy Konray, Esq. and Patricia Iyer, MSN, RN, LNCC, “Tampering with Medical Records”, Medical Legal Aspects of Medical Records, Second Edition