YouTube video – Medical Malpractice Claims: Have Your Records Been Altered?
Medical records are an enormous part of all medical litigation. When the case is under review, it may be noticed that data is missing, or that documentation does not accurately reflect the incident. The medical records may have been altered.
“Altering medical files does not happen as much as it seems to in the movies or on television. But, it happens enough that experienced medical malpractice lawyers develop a sense of when further investigation into the legitimacy of the medical records needs to be investigated,” John McKiggan.
This attorney discussed three of his cases that involved altered medical records.
- Nurse’s notes indicate that she spoke to the doctor regarding patient’s reaction to medication. When time sheets and shift records were checked, the nurse was not at work during the time when the note indicated. The lesson here is to investigate all records including time sheets in order to verify that everyone so says that they were there actually were.
- Doctor was witnessed tearing up a record and replacing it in the chart. A nurse taped the record together and kept it in her locker. The lesson here is to interview everyone involved in the case to see if they have information that my help a client.
- Apgar score whited out and changed on the record. It is not obvious on the photocopied record. But, can be seen on the original. The lesson here is to make a trip to see the original records if the copy looks suspicious.
“Altering medical files is not something that happens in every case. It is not even something that happens in most cases,” John McKiggan.
How do you see what really happened?
There are red flags to determine if further investigation for altered medical records is necessary, such as notes appearing self-serving on the healthcare provider’s behalf. Legal nurse consultants (LNCs) read through every page of the medical records. The key is that an LNC will highlight what may be missing from medical records based on experience and training. Non-medically trained staff going over the records will miss this. Documentation of the incident will be painstakingly examined.
Utilizing clinical experience, nursing proficiency, and familiarity with health-related systems, LNCs notice missing documents, highlight inconsistencies, and deliver a complete yet easily understandable summary of the health-related matters. Sequence of entries in to the chart will be scrutinized to examine for altered records.
When it comes to organizing, summarizing, and interpreting medical records, LNCs conduct a thorough medical record review, and will avert issues that a person without a medical background will not. Testimony of the client that conflicts with the medical records will be explored. After reviewing medical records, an LNC can evaluate the delivery of healthcare.
Do not risk missing a crucial piece of evidence of tampering in the medical records. Let us help you discover altered medical records. Contact Krug Consulting for your next medically related case.
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