IME,Inc.
211 Beaumont
Traverse City,
Michigan MI 49684
Tel: (800)
968-4637
(800) 968-4637 |
Independent Medical Evaluations, Inc.
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Detecting Altered Medical
Records Tampering with medical records may occur in
any medical or nursing negligence claim.
Tampering is most likely to occur when the provider panics
after a bad outcome has occurred. The temptation to polish wording
by rewriting pages or to destroy documents may be overwhelming.
The inference created by tampering with the records is that
the provider is trying to hide something. Several states recognize tampering with
records as a separate tort action. The jury charge of spoliation
of evidence refers to the actual or attempted destruction of
records or evidence. The elements of the spoliation inference are:
As a legal nurse consultant I have been faced
with several cases that involved tampering with records.
A person with medical training best performs the detailed
and analytical evaluation. Both plaintiff and defense attorneys rely on
legal nurse consultants (LNC) to report that tampering with a
record may have occurred. Tampering
with medical records may result in extension of the statue of
limitations based on the premise that fraud has been committed.
The defense of a claim involving altered medical records
becomes enormously complicated.
Few defense attorneys want to take the risk that punitive
damages may be granted by a jury angered that records have been
altered or destroyed. One of my recent cases involved a nursing
home woman who developed multiple adverse changes in her physical
status, which the plaintiffs alleged were the direct result of
negligence. The resident developed malnutrition, dehydration,
contractures and sixteen pressure ulcers (five of which
deteriorated to stage IV). The defendant failed to produce
subpoenaed documents. The jury returned a unanimous plaintiff
verdict, and awarded $2,710,000 for pain and suffering,
impairment, disfigurement, and mental anguish of the decedent in
the two and one half years of care before her death. They
additionally awarded $310,000,000 in punitive damages.
This case was tried in Texas. As a legal nurse, I begin an evaluation of a
case by determining if any documentation is missing. The easiest
way to determine if all of the components of the chart are present
is to use a set of indexes. Sorting
records using indexes is invaluable in revealing that entire
sections of the medical record are missing. When reviewing a case, the LNC needs to be
familiar with the typical components of the facility’s chart.
There are specific records, forms, and means of charting for each
health care facility. You must know the chart and what useful
documents to examine and detect discrepancies. Records should be examined for late entries,
large gaps in time without documentation, chart entries that are
out of order, words added to the notes, and failures to identify
the circumstances of an injury. The facility may maintain a
logbook that is used for shift-to- shift communication.
Notes that are handwritten at times and typed at times set
up red flags to what is the normal and customary way for the
facility to chart. Health care in correctional facilities are
the biggest offenders of tampering with medical documentations
especially if an adversary outcome has transpired.
A pending case of a wrongful death of a 20
year old inmate demonstrated delay of two and one half months
before documentation was turned over to the family and plaintiff
attorney. Some of the records were retyped others hand written.
The medication sheet had several different versions with dates
crossed out; dosage of drugs crossed and written over, sometimes
the medications were circled and sometimes there were Xd out, and
other times a line was drawn through the times.
Medication was charted 5 days after the young mans death.
The case is pending with 16 counts of fraud,
gross negligence, malpractice and breech of standards of care. Author Jan Parrish, RN, BSN, LNC Legal Nurse Consultant
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Independent Medical Evaluations - IME , Inc. provides expertise in many legal and medical situations including the following: Independent Medical Evaluation, Independent Medical Exam, Independent Medical Examinations, Impartial Evaluations, Physician Panel, Permanent Partial disability Examination, Medical Fraud Investigation, Medical Discovery, Expert Witness, Expert Witnesses, Medical-Legal Experts, Legal Nurse Consultant, Depositions, Live Testimony, Legal Nurse Consulting, Tort State, Personnel Injury, Defense Exams, Legal Nurse Consultants, Plaintiff Exams, Criminal Medical, Civil Medical, No Fault / Liability, Medical Claim, Medical Consultant, Insurance Medical Claim, Workers Compensation, Impairment Evaluations, Unbiased Medical Opinion, Disability, Medical-Legal Professionals, Certified Independent Medical Examiners, American Board of Independent Medical Examiners, SEAK, American Academy of Disability Evaluating Physicians (AADEP), Work Injuries, Auto Injuries, Car Accident Claims, Family Medical Leave (FMLA), Auto No Fault, Independent Medical Opinion (IMO), Medical Review, File Review, Medical Chart Review, Peer Review, Standards of Care, Malpractice, Medical Case Discovery, Medical Investigation, Long Term / Short Term Disability, Sickness and Accident, Early Assessments, Medical Illustrations, Auto Tort, Panel IMES, DNA Testing, Biomechanical Evaluations, Fitness for Duty, Physician Panel, Discovery, IME, Medical Malpractice, Compensibility, Management, Return To Work Issues, End Point, Maximum Medical Improvement, Orthopedics, Orthopedic Surgeon, Neurologist, Neurology, Physical Medicine, PMR, Psychiatry, Psychiatric, TMJ Specialist, Chiropractic, Chiropractor, Neurosurgeon, Neuropsychologist, Neuropsychology Testing, Plastic Surgeon, Oral Surgeon, ABIME, Disability Consultants, Psychologist, Psychology, MMPI, Nationwide Medical, Employer Health, Drug Testing, NIDA Labs and more.
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