Magazine article Medical Economics

Malpractice Consult

Magazine article Medical Economics

Malpractice Consult

Article excerpt

The legal risks of correcting patient records

I specifically told a patient to take iron. But I neglected to note this in her chart on the day of her visit. So I added it a week later when I was viewing my notes. Now she's suing me for something else, and this "alteration " is turning into a big issue. Is it always wrong to add Facts at a later date?

No. Reviewing your records to check for accuracy and completeness is common and commendable. Adding a note that you had prescribed iron shows that you were careful enough to review your notes and concerned enough to add the missing information. However, you must accurately date such a new note.

Never amend your clinical records after an attorney has requested them or commenced litigation against you. Any additions or corrections made at that time will be seen as an attempt to cover up mistakes and strengthen your defense. You can be sure that the alterations will be detected. It's also likely that the alteration would turn a jury against you. You could also face criminal and professional-misconduct charges, and conceivably blow your malpractice coverage.

Here's the proper way to amend your records: Write a new note at the end of the progress notes. Refer to the earlier note in which information is missing. Include the actual date of the addition.

What should you do if you discover an error rather than an omission in your notes? Draw a line through the erroneous information, but make sure that it's still legible. Never try to erase or otherwise take it out. Write an additional note correcting the information and date it. Write down the reason for the error, or the reason the error was noticed, to explain why the correction was needed at the later date.

When success can be held against you

A plaintiff's attorney is claiming that because I have such a busy practice, I didn't devote enough time to his client and therefore missed a diagnosis. …

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