If you suspect that a doctor or nurse forged your records to hide medical errors or mistakes, I suggest that you immediately hire a top-rated experienced Texas medical malpractice attorney to investigate your potential case.
I have to admit, I’m not a conspiracy theorist and think that most healthcare providers make accurate, although often incomplete, entries in patient medical records. That’s not to say, though, that phony records never occur. In fact, I’m quite certain I’ve seen them in several cases.
Until recent years, all medical records were considerably easier to fake because they were handwritten. It’s surprising, but some facilities still use handwritten records at least in part, like the notoriously hard-to-read physician notes.
I’ve seen situations where an entire page of handwritten records looked re-written as part of a cover-up. This may require hiring a forensic documents examiner to review the original documents. These experts are very interesting to watch. They compare things like the ink type and appearance, writing pressure, and writing characteristics on the page in question versus adjacent pages in the chart.
With the widespread adoption of electronic records, in-the-know medical malpractice attorneys can take advantage of detective-like tools to investigate whether a records has been doctored. Some of them include:
• Comparing medical records obtained by the patient during treatment to records ordered during the investigation, to look for discrepancies. At Painter Law Firm, our experienced medical malpractice attorneys work with legal nurse consultants to review and compare medical records closely.
• Ordering the audit trail related to suspicious parts of the records. Electronic medical records must have audit trails that record the user identification (ID), date, time, and location of every entry in the medical record. This includes edits, changes, and deletions to any part of the chart. If someone accessed the medical record to change something after the fact, there should be a record of it in the audit trail.
• Ordering the billing records. The billing software is different from the medical record software. Many drugs and items are automatically billed when dispensed. When the bill differs from the medical record, it can verify that something fishy is going on. Plus, it would be difficult for a dishonest doctor or nurse to fake both the medical and billing records of a patient.
• Taking depositions of the providers involved. A deposition is sworn testimony recorded and transcribed by a court reporter. The transcript or video can be played for the judge and jury during trial. When I have questions about the reliability of the medical records, I depose all nurses, techs, therapists, and physicians involved in the care at issue. In my experience, when a health care provider is fabricating a story, not everyone will go along with it, and a deposition is a good way to uncover it.