How do Medical Staff Tamper with Medical Records?

There are many reasons why a person would tamper with medical records, including an intention to commit fraud, such as billing for services not performed, or fear or guilt when an untoward outcome occurs. The LNC should be aware of the potential for tampering when there is:

• a delay in or an inability to obtain medical records;
• an unexpected event has occurred, such as an elopement, paralysis from an injury, a fracture, a burn, or whenever there is a medical catastrophe;  or
• too good to be true documentation such as perfectly stable weights.

These are some techniques used to tamper with medical records.

1. Adding to an existing record at a later date

In reviewing medical records, the LNC may find incomplete records. One of the roles of the medical records department is to review the chart at the time the resident is discharged and to ask the physician to complete the chart.

Many risk managers attempt to prevent tampering by securing the medical record after a patient has sustained an adverse outcome. Healthcare professionals are taught that the correct way to add to an existing record is to document the time and date that the addition is being made. The addition should not be squeezed into an earlier entry but should appear on the next available line in the medical entry.

An audit trail of an electronic medical record will reveal the time an additional entry was made.

2. Placing inaccurate information into the record

False information in a medical record can sometimes be hard to detect after the fact. At times common sense or the clinical knowledge of a legal nurse consultant or expert witness will lead to the suspicion that the documentation is not entirely truthful.

At other times, the plaintiff will convincingly assert that the information is inaccurate. Spoliation of evidence encompasses more than simply medical records. Other critical documentation can be altered, such as personnel records.

3. Omitting significant information

Omitted information on a flow sheet or a nursing form may be easy to spot. For example, some flow sheets are set up with blanks to be filled in at intervals, such as monthly weights. A flow sheet of this nature would be an important piece of evidence in a case involving malnutrition.

The deliberate omission of significant information may be more difficult to detect. Often, common sense is applied to identify the information that is missing. Inadequate record keeping complicates the defense of a facility.

4. Rewriting the record

One of the most damaging admissions occurs when a healthcare professional testifies that a medical record was rewritten. There can be completely innocent reasons why a medical record was rewritten.

Occasionally a paper page from a chart will be recopied if it is torn or liquid is spilled on it. The appropriate procedure to follow when this occurs is to identify the page as rewritten. The original page should be retained in the medical record. The deliberate rewriting of a record with attendant changes in the content, timing, and sequence of events is tampering with the record.

An audit trail will reveal when a note is rewritten.

Defendants should be carefully questioned when rewriting of the medical record is suspected. This issue can have a major impact on a case.

 5. Destroying records

The destruction of pages, sections or an entire medical record creates a strong suspicion that the information in the record was so damaging that it had to be concealed.

When a record or paper pages of it disappear, part of the discovery process involves determining who had access to the record. Missing records are always difficult to explain.

6. Adding to someone else’s notes

Even though it is unacceptable for one healthcare professional to alter someone else’s documentation, it happens, and more commonly than attorneys would believe. Physicians have altered nursing records, and nurses have altered each other’s notes. Physicians may be very casual about editing someone else’s notes because of the practice of overseeing the documentation of residents.

The additions to another person’s records as a form of tampering with medical records is easy to detect using an audit trail.

Tampering with Records Relating to Common Liability Issues

There are key outcomes that may stimulate a decision to alter medical records. These are examples of allegations of neglect in a long term care facility related to pressure ulcers, malnutrition and dehydration, physical and sexual assault, falls and fractures, and wandering.

1. Pressure ulcers in a nursing home

Infected or stage III or IV pressure sores are red flag issues that capture the attention of attorneys. Staff at healthcare facilities have yielded to the temptation to alter records after the development of pressure sores. The altering may include documenting care that was not given, such as turning and repositioning and wound treatments, or by minimizing the stages and locations of pressure sores.

Review of the medical record in a pressure sore case includes analysis of the following factors. Any of the nursing documentation forms may be falsified, including the long term care facility’s Minimum Data Sheet, flow sheets, nursing care plans, weight records, Braden and Norton pressure ulcer scores.

Further analysis should be performed to include

• comparison of hospital medical record with nursing home record if the resident was admitted to the hospital because of the pressure sore;
• review of the surgeon’s operative report (with attention to stage and dimensions) of a debridement or flap was performed at the hospital after transfer because of the pressure sore;
• comparison of the hospital’s and nursing home’s documentation to see if there is agreement on the stage and size of the pressure sore;
• comparison of the wound care center’s documentation about the pressure sore with the nursing home chart, if the wound care center has separate records
• examination of bills to see if charges were entered (if applicable) for pressure relieving surfaces and beds and the date such treatment began;
• review of photographs (if any) showing the size and locations of sores
  

  2.  Malnutrition and dehydration

Many malpractice, neglect, and abuse matters include allegations of malnutrition and dehydration. These conditions are red flag issues for attorneys.

Review of the medical record in the malnutrition/dehydration case includes analysis of the following documents, any of which may be falsified:

• meal intake record in comparison to records of weight;
• intake amounts in comparison to laboratory studies showing dehydration and malnutrition (low prealbumin, low albumin, high sodium);
• laboratory results for indications of impending renal failure, which may be caused by dehydration (high blood urea nitrogen and high creatinine)
• weight sheets to determine if there was a pattern of weight loss or an improbably stable weight
• speech and swallowing evaluations

Further analysis should be performed to include review of the

• photographs taken by the family of a malnourished resident in comparison to  weights recorded in the medical record; and
• emergency department records that indicate the resident was received in a malnourished or dehydrated state

Fecal impaction can lead to rupture of the intestines and death or the need for a permanent colostomy. Tampering with the records may occur if the staff is documenting the occurrence of regular bowel movements while the fecal impaction is developing.

3. Physical and sexual assault

Physical and sexual assault cases are red flat issues for attorneys.  Few cases are more potentially inflammatory. The analysis of these cases is complicated by the fact that some resident injure themselves, causing bruising. The aggressive, violent patient who is on blood thinning agents is particularly at risk for injury. Review of the medical record in the physical and sexual assault case includes analysis of the following documents. Staff might tamper with medical records in any of these ways by falsifying the:

• medication records to determine if the resident was being given Lovenox, Coumadin (warfarin), or other anticoagulants;
• nursing care plan to see if the resident had a history of aggression or self mutilation;
• personnel files to determine if the facility performed an appropriate background check of employees;
• nature and description of the injuries in comparison to the status of the resident to determine if the resident could have truly injured himself;
• nursing notes and physician progress notes to see if the documentation of bruising matches;
• photographs of injuries;
• radiology reports for spiral fractures, particularly of the arm, which can occur when the wrist is grabbed and the resident’s arm is twisted;
• mandatory reports submitted to the Department of Health; and
• emergency department records and photographs for descriptions of the injuries

4. Falls and fractures

Falls and fractures are a major cause of disability and death in the elderly and often initiate a downward spiral in health. A fall may lead to immobility, pressure sores, pneumonia, and death.  Analysis of the medical record of a resident who falls includes review of documentation.

The key documentation in this type of case includes nursing care plans, falls risk assessments, MDS and RAPs, risk assessment forms, nursing notes describing events leading up to the fall, incident report. Any of this critical documentation may be falsified.

5. Wandering and elopement

The frightening announcement that a resident has disappeared typically sets off an intensive search for the missing person. Medical record documentation is likely to occur after the disappearance. Analysis of the medical record should include review of the following material, any of which may be tampered with:

• nursing notes to determine if the resident was identified as a wanderer;
• progress notes to determine if the resident made previous attempts to leave
• nursing care plan for evidence of identification of wandering behavior;
• interdisciplinary review team analysis of the strategies effective in reducing wandering, such as diversion, moving the resident to a room closer to the nurses station, applying wanderguard devices, and implementing a regular toileting schedule;
• revision of the plan of care if the resident was successful in leaving the facility at least once before the incident that led to injury;
• Social Services notes in the event that the facility was unable to safeguard the resident. There should be evidence that the facility attempted to find an alternative location for the resident, and
• Police reports correlated with nursing home documentation about the incident.

Tampering with the records can have profound implications for the attorney and defendant. It will make the defense of a malpractice case difficult and the pursuit of a settlement easier for the plaintiff. The attorney who suspects that tampering has occurred needs to obtain validation of these concerns in order to make the appropriate strategic moves.

The ability to decipher and interpret nursing documentation is often the key to analyzing a nursing home negligence case. A malpractice case can be won or lost on a few words in a medical record. It is essential that the attorney be able to review and understand medical records to make appropriate legal decisions and be guided by the advice of skilled experts and legal nurse consultants.

Want to sharpen your ability to analyze medical record, detect tampering with medical records, and prepare sample reports to show attorneys your skills? Join us for our most popular course, Report Writing Mastery, starting September 16, 2025, the first of 5 evening sessions. Sign up here.

Pat Iyer is president of The Pat Iyer Group, which develops resources to assist LNCs in obtaining more clients, making more money, and achieving their business goals and dreams.

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