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Altered Records

It is important to be consistent in the keeping of records. Attorneys and juries are suspicious of inconsistencies. If records are usually handwritten, a dictated note will be questioned. Conversely, a handwritten note in a series of dictated notes will be suspect. As discussed in the section on business records, the essence of a credible record is that it appears to have been maintained in the regular course of business. Anything that indicates special treatment for a record reduces its credibility.

Physicians should not alter their medical records under any circumstances. Hospitals guard medical records from alterations, but there is no such watchdog in a physician's office. Even an inconsequential alteration throws the validity of the entire record into question. Innocent mistakes, such as the loss of a few pages of a record, will be construed as an intentional cover-up. Under no circumstances should liquid correction fluid be applied to the record in order to correct an entry. 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, with the date of the new entry and the initials of the person making the entry recorded. It is important that the entry include the reason for its inclusion--perhaps newly available laboratory information, addenda to explain a previous note, or just that it is a supplemental note. As long as it is clear that no deception is intended, physicians should not hesitate to supplement chart notes. A note supplemented two weeks after the original entry is more credible than attempts to supplement it on the witness stand five years later.


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