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Altering records: discrediting your best witness
1Risk Management, MAG Mutual Insurance Company, Atlanta, GA 30305.
Journal of the Medical Association of Georgia
|February 1, 1993
Summary
Properly correcting medical records is crucial for professional liability defense. Incorrect entries can be exploited by attorneys, potentially increasing case value and encouraging settlements.
Area of Science:
- Medical record management
- Legal medicine
- Healthcare documentation
Background:
- Medical records are legal documents.
- Improper corrections can jeopardize legal defense.
- Attorneys may allege altered records to influence case outcomes.
Purpose of the Study:
- To outline the criteria for sound medical record corrections.
- To highlight the risks associated with improper documentation.
- To advise healthcare professionals on best practices for record alteration.
Main Methods:
- Review of legal strategies concerning medical record alterations.
- Analysis of criteria for valid medical record amendments.
- Guidance on contemporaneous and relevant documentation.
Main Results:
- Proper corrections must be contemporaneous, relevant to patient care, and consistent with existing records.
- Improperly made entries can undermine professional liability defenses.
- Allegations of altered records are a common plaintiff strategy.
Conclusions:
- Adhering to specific guidelines for medical record correction is essential.
- Meticulous and accurate record-keeping protects against legal challenges.
- Avoid embellishing or amplifying actions in record corrections to prevent exploitation.