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Altered Records

The health care provider should not alter the medical record under any circumstances. The hospital must zealously guard its medical records from alterations by physicians or members of the nursing staff. Even an inconsequential alteration will throw the validity of the entire record into question. If an entry must be changed, a single line should be drawn through the entry, taking particular care to make sure that the original entry is clearly legible. The new entry should be written above or next to the old entry, and the date of the new entry, as well as the name of the person making the entry, should be recorded. The entry must also be signed by that person. Juries are very intolerant of altered medical records; and even innocent mistakes, such as the loss of a few pages of a record, will be construed as an intentional coverup. Under no circumstances should materials such as liquid paper or other opaque liquids be applied to the record in order to correct any entry.


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