The physician receives a request for a copy of the electronic health record from an attorney for a patient. The physician reviews the medical record and finds that a progress note contains inaccurate information. The physician then deletes the visit and retypes the progress note incorporating the now known information. At lawsuit, there are two records produced by the plaintiff indicating the record was changed. How? The physician had sent a copy of the original progress note to the specialist/referral.
When documenting patient encounters, CAP physicians are encouraged to review their notes prior to signing. If there is a need to correct, modify, or change the record, you should identify the note, enter the new data, and/or refer to the specific encounter, if necessary.
What if you discover an error or need to make a late entry after you have signed the record? The physician should create an addendum to the electronic medical record, and refer to the specific encounter, if necessary.
In the hospital setting, the procedure for adding or deleting in the medical record remains the same. Physicians are encouraged to create an addendum, indicating changes. Never alter the medical record, even if the system allows you to do so.
All EMR/EHR systems save every key-stroke in the "background" metadata files. Altering the medical record after signing off is discoverable. Plaintiff's attorney can subpoena the records and have access to all documents, whether hard copy or electronic. They can also use experts to identify discrepancies in the metadata files.
Your credibility and/or defensibility may be at risk for not making proper changes.
Authored by
Joseph Wager and Allan Ridings
Senior Risk Management & Patient Safety Specialists
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.