Altered Medical Records – OLD SCHOOL!

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ON ALTERED RECORDS

By Dr. David Edward Marcinko MBA CMP®

http://www.CertifiedMedicalPlanner.org

DEM white shirtThe health care provider should not alter the medical record under any circumstances.

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.

Assessment

The health care provider should not alter the medical record under any circumstances.

Conclusion

Is there an emerging migration back to paper medical records?

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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:

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

 Harvard Medical School

Boston Children’s Hospital – Psychiatrist

Yale University

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One Response

  1. Paper records are the way to Go

    “Paper records are the way to go, says Brase.” By Chris Woodward (OneNewsNow.com) for NE News Now, March 7, 2016.

    http://www.onenewsnow.com/business/2016/03/07/paper-records-are-the-way-to-go-says-brase

    What if it is discovered that dentistry performed without electronic dental records is just as good as dentistry performed with dental EHRs – which are both more expensive and more dangerous than paper?

    Darrell K. Pruitt DDS

    Like

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