Will a Doctor or Hospital Alter My Medical Records?

Imagine a doctor admitting to you that years before your devastating diagnosis the doctor had received important test results but, due to oversight, never told you about them.  Now imagine you hire a medical malpractice lawyer who requests all of your medical records to prove the case – but instead of the truth of what did not happen,  your doctor’s notes say he told you about the test results and you indicated that you understood but did not want the treatment.

Your medical malpractice case has been dealt a devastating blow because your medical records have been altered.  This nightmare scenario that has played out in countless medical malpractice law suits leads many of our clients to ask – will they alter my medical records?

Can They Alter My Medical Records?

The short answer is “yes.”  In Pennsylvania, it is still possible for doctors, nurses and hospitals to alter your medical records after the fact – but it has gotten harder to get away with.

In the past, when patient medical records were documented on paper only, it was easy for healthcare providers to change medical records in order to get away with medical malpractice.  All it took was an additional hand-written entry or a simply replacement of the document in question.

Fortunately, technology, specifically electronic medical records makes it much more difficult for defendants to get away with altering your medical records.

Doctors and nurses are still able to make modifications to your records but now there is an electronic record of everything anyone does to your medical records called an audit log.

Are There Penalties for Altering My Medical Records?

Yes.   Pennsylvania’s Medical Care Availability and Reduction of Error (MCARE) Act, requires a patient’s chart to be created simultaneously with the treatment or as soon as practically possible.  The MCARE Act requires that any later additions or modifications to a patient’s medical record must clearly identify the time and date of the change and who made it.  If a doctor or nurse violates the MCARE Act, his medical license is subject to suspension or revocation.

Additionally, at trial, if the patient’s lawyer proves there was an intentional alteration or destruction of your medical records, the Court will instruct the jury to infer that the records were changed because the true record was unfavorable for the defendant doctor or nurse.   This may not sound like a lot but when a jury hears a judge tell them to consider the possibility that the defendant may have been acting with a bad motive it can lead to much larger than usual jury verdicts.

Will My Medical Malpractice Lawyer Make Sure My Records Have Not Been Changed?

Any Pennsylvania medical malpractice lawyer worth their salt will obtain the audit log of your electronic medical record to make absolute certain the record had not been altered after the fact.  The audit log is the only way a patient has to know who was in their medical record, what they were doing and when they did it.  We make sure to get the patient’s audit log in every medical malpractice case we handle when there is even the slightest indication of medical record alteration.

You should insist your medical malpractice lawyer secure the audit log if you have any question that your medical record has been altered.

If you have questions about electronic medical records and medical malpractice, please call us at (412) 281-4100 to schedule a free case evaluation.

All articles in this blog are the collaborative effort of attorneys Jerry Meyers, Brendan Lupetin, and Gregory Unatin.

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