It is important to be consistent in the keeping of 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. 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.
Medical care practitioners should not alter their medical records under any
circumstances. Hospitals protect 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 new 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.