Patient Records In a Malpractice Case

We’ve posted about the importance of keeping thorough patient records to justify the choices and actions of a health care professional. In this article we talk about another crucial factor: Alterations of patient medical records.

Regardless of your intention, a record should never be altered. An addendum, or additional comment may be acceptable, but if it is noted that a record has been altered for ANY reason, the jury will be informed, and the consequences can be dire.

It has been consistently shown that medical malpractice juries tend to defer to the physician, to believe the doctor’s opinion and, usually, to trust the doctor initially. But if a record has been changed in any way, that trust is gone, and the jury is patently suspicious. White-out, strike-out, a hand-written note squeezed in after the fact, these are all reasons for suspicion to a jury, no matter if the doctor is simply intending to clarify or actually means to deceive.

When a jury finds that a patient’s records have been changed, they are able to levy punitive damages in a medical malpractice suit. This amount can be considerable, and the legal system concurs that it is appropriate, to discourage such behavior in the future. Of even greater importance to the physician is the fact that punitive damages may be specifically excluded from the Professional Malpractice insurance policy. If that’s the case, the physician will be personallyt responsible for that amount. One case, wherein a patient’s malignant tumor was ignored, resulting in the loss of a limb and eventual death from that cancer, saw a 3 million dollar additional punitive award, because the physician had attempted to conceal the malpractice on the records. The amount was later reduced to 1 million, but that’s still a lot to be paying out of pocket.

Patient records can stand behind a physician or healthcare provider’s work, protecting him from an unwarranted allegation. They can also indict that physician, destroying both credibility and defense, if shown to have been altered. The best defense is to simply be honest, and document thoroughly in the first place.

Visit the Presidio Medical Malpractice Insurance website for complete coverage information and products lines.

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