In Part 1, I explained how you can spot substandard charting. Suspicious charting goes one step further to raise concern about the medical records.
Substandard Charting or Fraudulent Charting
Trouble: Detailed addenda
Healthcare providers may feel compelled to write detailed addenda to the medical record after they learned a patient was injured or was considering filing a malpractice claim. These notes, while probably accurate and legitimate, look suspicious and self serving. Often they 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. Physicians must not give into the temptation to add to or subtract from the medical record.
What were the pressures?
In a California case, a woman claimed she specifically stated she did not want instruments, such as a vacuum, used during delivery. The obstetrician used a vacuum to deliver the baby’s head during the cesarean section. The child suffered intracranial hemorrhaging, severe brain damage, and blindness. He will probably sever speak or walk.
The obstetrician amended his dictated operative note by hand and then again by dictation to reflect the use of the vacuum and what he believed to have been the pressure used. The labor nurse amended the mother’s chart and labor and delivery record to reflect the use of the vacuum.
The labor nurse noted higher pressure settings than did the physician’s report. The hospital reached a $3.5 million settlement prior to trial. A defense verdict was reached on behalf of the physician. (1)
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. Substandard charting or fraudulent charting greatly complicates defending a medical malpractice case.
Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. Pat shared what she knows about altered medical records in a webinar on the topic. Get details on how you can benefit from this knowledge.
(1) Laska, L. “Woman claims she specifically stated she didn’t want instruments, such as a vacuum, to be used during delivery and chose elective cesarean section.” Medical Malpractice Settlements, Verdicts, and Experts, March 2009, p. 40.