Medical records of the patients are legal documents that are governed by both federal and state legislation. They are considered valid evidence in medical-legal cases. Hence, the process of making any necessary changes to medical documentation is governed by state legislation. As a result, if these procedures are not followed, it is considered falsification of medical records, also called medical record tampering. Physicians and healthcare providers may face significant liability for any illegal changes in a patient’s medical chart.
According to medical malpractice law, a medical decision, treatment, or a procedure is not done if it is not noted in the medical record. Hence, any information about a patient’s illness, diagnosis, or treatment should be documented in his medical records.
The following are considered as medical record tampering.
- Erasing a diagnostic report
- Making illegal corrections
- Inserting information without standard documentation
- Changing or destroying the record
- Omitting key facts
Tampering of medical records may be done to hide medical malpractice or to conceal the damages sustained by a patient due to the carelessness of a healthcare professional. When the injuries of a patient move to a lawsuit, and there is solid evidence in the medical records, it may provoke the defendant to tamper with the medical charts.
Looking for inconsistencies in the date of treatment, overwriting in the handwritten notes, missing relevant medical charts, etc., may indicate the possibility of tampering. Though patients can request and access their medical records from the healthcare provider, it is not an easy job to identify tampering.
Falsification of a medical record, as well as any alteration or destruction of the original data, is considered tampering with evidence in a medical malpractice claim. This is a cause of action that allows the plaintiff to receive compensation in most jurisdictions. Falsifying medical records on purpose is a felony punishable by a $250,000 fine or five years in jail. A court may sanction punitive damages in addition to compensating the victim to deter the manipulation of medical data.
Outsourcing medical record review is an excellent option to identify if any falsification has been done in the claimant's medical records. This may turn out very crucial in medical malpractice lawsuits. Expert medical record reviewers and legal nurse consultants can swiftly identify data that is missing, incorrect, or out of order. In cases of suspected medical record fraud, a legal nurse consultant can easily spot out the tampering.