Falsifying medical records is no easy feat. Proving that it has occurred can be just as challenging. Patient medical records are legal documents, and courts of law do not typically respond favorably to evidence suggesting that they have been tampered with or altered. Knowing that there are standard methods in place to responsibly document legitimate changes, juries are often suspicious of tampering claims.

Records of medical events and claims are expected to be completed once a patient is discharged from a facility. If a change to a medical record is justified, states have their own laws on how medical data may be modified.

When modification of the record is appropriate, original entries are never simply obliterated from medical documents. Electronic health record (EHR) systems have procedures in place by which changes in medical records are made when the situation is fitting.  Unique to EHR is the audit trail, a record detailing each person who accesses the record system, when the system was accessed and what changes were made when the record was opened. All this makes it challenging for falsifying and tampering with medical records to go unnoticed.

Anyone tempted to commit medical record fraud knows that a host of co-workers will carefully document their own records for their own legal protection. Deceptive changes can conflict with colleagues’ notes and billing records. Many professionals are aware that forensic experts can analyze both physical and electronic records for tampering, even determine the times and identities involved in a suspicious entry. Knowing all this, most healthcare providers will not risk prosecution, board discipline, or loss of licensure, insurance or employment.

But record falsification does happen in the healthcare community. Often it is an attempt at damage control when an error is known, a negative medical outcome occurs, or a lawsuit is filed. Records have been altered by greedy physicians who billed for unperformed services and by frustrated home health care nurses whose clients repeatedly curtailed their hours without notice. Falsification and tampering come in many forms – removing a diagnostic report, inserting information without standard documentation, rewriting or destroying the record, omitting significant facts or even creating records for nonexistent staff.

Sometimes a deception is spotted easily.  A defendant changes chart information after a lawsuit is filed, unaware that the patient’s attorney already has an earlier version of the record. “Doctored” data can throw off the chronology of events or have the patient in two places at one time. In other cases, fraudulent intent is not so clear.

Red Flags for Medical Record Falsification

Legal teams should know the potential for wrongdoing in certain circumstances – any medical catastrophe, surgical error, unexpected death, hospital-acquired condition, or unexpected facility event (a patient leaving without being discharged.) Knowing that a patient’s legal representative is seeking a copy of the medical record should be the first cue to look for signs of record falsification. Records which are not produced in a timely manner are a definite red flag.

Once those materials are acquired, look for incomplete, sparse, or incredulous information about the event that resulted in harm. Were non-emergency services provided on a date that falls on a weekend – or during a natural disaster in the locality? Is there a conflict between the documentation and what the patient has said?  Do the provider progress notes clash with X-ray, lab or pharmacy data? If the result of the injury does not jibe with the documented record – or if the complaints of a patient suing the facility align too well with information that happens to be missing – a healthcare expert should be brought in.

Nurses know precisely what standard information should be entered in the medical record. They can quickly spot missing, inconsistent, or out-of-order data. This makes a legal nurse consultant (LNC) a particular boon in cases suspected medical record fraud.

LNCs work with medical, pharmacy and employment records on hand to create an accurate timeline and determine inconsistencies. They are in a unique position not only to analyze the information contained within the records, but also to pinpoint what is missing and recommend items to obtain.  Your LNC can interview potential new clients, screen a case for merit, and identify issues related to liability and deviation from standard of care.  He or she can provide questions to ask in a deposition and then summarize the testimony given on the record – another opportunity to identify missing or misleading information.

Regardless of the venue or task at hand, the legal nurse consultant is perhaps the most cost-effective key player on your legal team.