The attorney tells you she has a suspicion that the medical record has fraudulent charting. She thinks the medical documentation of healthcare providers may be incomplete, untimely, illegible, or incorrect.
You know that substandard documentation may itself result in an untoward outcome for the patient and thus factor into a medical negligence suit. However, what separates it from tampering is that it is due to a reason other than a desire deliberately to destroy, suppress, or otherwise tamper with medical records.
Incomplete charting may be substandard charting or fraudulent charting
Incomplete documentation night occur when a healthcare professional begins to document on a medical record and then is called away to do something else. A brief note written under the pressure of time may be interpreted as an inattentive interaction. Notes that are ambiguous or too brief include entries such as
- • OK,
• looks fine, or
• review of systems within normal limits.
The incomplete notes may contribute to a negative clinical outcome when the missing information would have been important for others to know.
Untimely documentation may result when the medical record is not available for charting, although this is less common now since more documentation is electronic. The dictation of a history and physical, operative report, consultation, or discharge summary occurs too long after the events in question. Sometimes the physician does not dictate the discharge summary within the required thirty-day timeframe because the hospitalization is lengthy and it is difficult to set aside the time needed to perform this task.
Hospital administration may suspend the admitting privileges of physicians if they are habitually late in completing discharge summaries.
Reports dictated too long after a complication lack credibility, whether or not the outcomes resulted from negligence.
Illegible handwriting is a major source of frustration for all those who have to rely on being able to read medical records. Unreadable handwriting may affect the clinical care of the patient.
Malpractice carriers report that illegible handwriting may lead to some of their most expensive and difficult to defend lawsuits.
Incorrect information may appear in medical records. Wrong information is entered into the medical record because of distractions, fatigue, or other factors.
Errors and inaccurate charting may result when the medical or nursing staff begins to document in a rote manner. For example I read a chart of an elderly woman being treated for a hip fracture. A note written by a student nurse (and cosigned by her instructor) referred to the patient as a male intravenous drug abuser being treated with methadone!
Forms may be incorrectly used due to lack of education about the correct use of the form. Agency personnel or new employees may not have received education on the use of the documentation system. Supervisory staff is responsible for overseeing the documentation of the workers to ensure that forms are being correctly used. Appropriate orientation to the facility’s documentation standards should be provided to new employees, temporary workers, rotating interns, residents, and so on. Problems in charting develop
- when forms are used for the wrong reasons,
- introduced without education on the use of the form,
- are redundant with other documents in the medical record, or
- too complicated for the staff to use.
Errors made by transcriptionists may not be detected if a physician does not take the time to review dictated reports. Some doctors ask a transcriptionist to stamp a report with the words “dictated but not read” in the belief that this disclaimer excuses them from correcting errors on transcribed reports. In fact, such a disclaimer may increase liability.
Suppose the doctor does not review a record that contains dictation errors. These errors injure the patient. the plaintiff attorney may assert the doctor was “too busy” or “too unconcerned” to ensure the accuracy of an operative report, history and physical, or consultation report.
Healthcare providers may feel compelled to write detailed addenda to the medical record after they learned a patient was injured or was considering a malpractice claim. These notes, while probably accurate and legitimate, look suspicious and self serving. Risk managers hate them!
Often the late entries include more examination details, lengthier notes about treatment, discussions with the patient, and post-treatment advice than was originally documented in the record.
Claims managers call them panic notes because they are almost always written after the healthcare provider learns that there might be a lawsuit. Claims managers encourage physicians to put the medical record in a secure place within their office after learning of a lawsuit. They advise physicians to not give into the temptation to add to or subtract from the medical record.
At times, information is charted in more than one place and is inconsistent. The inconsistency raises questions about which are the accurate data.
The legal nurse consultant’s role is to spot inconsistencies, inaccuracies and other evidence of substandard, suspicious or altered medical records. The attorney’s role is to determine the significance of these issues on the case. Read more in Part 2.
Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. Pat shared what she knows about altered medical records when she presented a webinar on the topic. Get details on how you can benefit from this knowledge.