Altering Medical Records

Importance Of Medical Records

Medical records are the backbone of any medical malpractice case.

Before a patient can file a lawsuit against a physician, nurse or a medical facility in Florida, medical experts are required to review sign an affidavit attesting that there is a good faith basis to claim that there was a breach in the standard of care. These experts rely primarily on the patient records to determine whether another doctor did not provide the care any reasonable doctor in the same position would. If a physician, nurse, or medical facility has been altering medical records, then a victim of negligence may not be able to pursue their claim.

How To Spot An Alteration

Be sure to request your own set of medical records when you commence a lawsuit. This will not only give you the full scope of your medical history and treatment, but it will serve as a reference point for any other subsequent records send by the opposing party. If you notice any differences in your copy of records and any other copy, make sure to note the discrepancy and inform your attorney.

Sometimes the easiest way to verify that a record was not altered is by checking the date and time of each note. Many hospitals are now using electronic medical records (EMR). Many of these EMR programs allow doctors and nurses to add notes while the system automatically generates the date and time of entry. Meaning, doctors cannot manually alter the date or time on the note entered into the system. This is often referred to as an “audit trail.” If you see a note whose date or time does not align with the when you were under the care of medical professional, this could mean that the medical records were tampered with.Something else to lookout for is a lack of dates and times. As mentioned above, the record’s date and time are usually generated automatically, so a lack of information about the when the note was entered is something to be aware of when reviewing your medical records.Though your attorney will be vigilant of anyone altering your medical records, you should still report any suspicious or missing entries to them.

Consequences Of Alterations In Florida

Florida law prohibits altering a patient’s medical records. Anyone who alters medical records can potentially face severe consequences.

Florida Statute § 395.32 states:(1) Any person who fraudulently alters, defaces, or falsifies any medical record, or causes or procures any of these offenses to be committed, commits a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.(2) A conviction under subsection (1) is also grounds for restriction, suspension, or termination of license privileges.

Cases

It is not uncommon to find cases of altering medical records. Keep in mind, changes to the records are not always made because of possible litigation.

For example, in a Florida case, Araujo v. Eisner (2015), an anesthesiologist manually changed a patient’s Co2 levels during surgery. The patient in that case suffered a stroke due to an air embolism. Though her Co2 levels were consistent with an air embolism, her other symptoms were not. Therefore, the doctor suspected the monitor was malfunctioning and, as a result, he changed the chart to reflect what he thought was the proper Co2 level.If you suspect your patient records were altered, you should contact an attorney immediately.

Medical Malpractice

If you believe you or a family member has a medical malpractice claim because of the negligence of hospital nurses or doctors, you may be entitled to compensation for your damages. Call Bonner Law at 1-800-4MEDMAL for a free consultation.

Michael P. Bonner has over 30 years of experience representing clients in medical malpractice litigation.