There are valid instances when correction of an erroneous entry, late entries of necessary clinical information, addendums to prior entries, or amendments to the medical record need to occur. In these instances, appropriate steps should be taken to clearly document who made the entry, when the entry was made, and why the entry was made.
There are valid instances when:
In these situations, appropriate steps should be taken to clearly document:
Changes to the medical record should not be made after the record has been copied and released, such as to an attorney. Any changes to a record after a copy has been released results in two versions of the record. In the event of a lawsuit, suspicions of record alteration will be raised. Any hint of record tampering may completely shatter the credibility of the record and of the defendant and may lead to a plaintiff's verdict, regardless of the medical facts or merit of the case.
Never alter a medical record. If it is determined that medical records have been changed without justification, the credibility of the entire record may be destroyed. Not only will record alteration severely damage the chances of prevailing in a lawsuit, but it may put professional liability coverage for the incident at risk.
There are circumstances where corrections, late entries, addendums, or amendments to a medical record may be appropriate. When changes are necessary, documentation should clearly identify who made the entry, when it was made, and why it was made. Medical records should never be altered without justification, and records that have already been released should not be changed.
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Disclaimer: The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change.