ON ALTERED RECORDS
By Dr. David Edward Marcinko MBA CMP®
The office, clinic or 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 cover-up. Under no circumstances should materials such as liquid paper or other opaque liquids be applied to the record in order to correct any entry.
The health care provider should not alter the medical record under any circumstances.
Is there an emerging migration back to paper medical records?
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:
- PRACTICES: www.BusinessofMedicalPractice.com
- HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
- CLINICS: http://www.crcpress.com/product/isbn/9781439879900
- ADVISORS: www.CertifiedMedicalPlanner.org
- FINANCE: Financial Planning for Physicians and Advisors
- INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
- Dictionary of Health Economics and Finance
- Dictionary of Health Information Technology and Security
- Dictionary of Health Insurance and Managed Care
Harvard Medical School
Boston Children’s Hospital – Psychiatrist