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Medical Records Routinely Falsified

Pennsylvania medical malpractice lawyers have known for decades that medical records are often falsified by health care providers in order to make it appear the providers followed the rules even when they did not.  Now, a recent study of Veterans’ hospitals has shed public light on this depressingly common occurrence.

The study comes on the heels of allegations that patients died while awaiting care at Veteran Administration facilities.  To determine whether “cooking the books” was a systemic problem, the VA inspector general undertook an investigation. 

The investigation focused on the department’s rule that patients be provided an appointment within 30 days of requesting one and the “gaming strategies” that some health care providers employed to make it appear that the hospital complied with the rule.  These strategies included making “fake” appointments on an electronic scheduler that were never communicated to the patient but which made it appear that the hospital complied with the rule.  Other strategies included setting an appointment at the next available date, outside the 30 day window, but logging it into the system as a date the veteran had specifically requested.

I remember as a young lawyer when I was introduced to the concept of routine faking of medical records.  This was back in the time of paper records, before electronic audit trails.  I noticed that on medical charts there were large portions of the chart that were “X’d” out and that, below the x’s, a physician signature appeared.  I didn’t understand why this was such a routine occurrence.  “What purpose did the x’s serve?,” I wondered.

One day, an experienced nurse explained it to me.  Doctors, she said, would make their notes and write their orders and then sign their name several inches below the last of those orders.  Nurses who’d been around long enough understood that the doctors left that extra space so that later they could return and write in additional orders above their signatures to make it appear the orders were written earlier in time than they had been.  The effect was to make it appear the doctor had ordered a treatment or diagnostic test which a nurse failed to execute.  Savvy nurses would see this on the chart and immediately X-out the space between the last order and the doctor’s signature so that the doctor couldn’t add orders later in time and shift blame to the nurse.

Of course, the revelation in all this wasn’t that health care providers sometimes falsified records.  People have lied to protect themselves from the beginning of time and health care providers are no exception.  The revelation in all this is that everyone knew it was going on and everyone turned a blind eye to the practice. 

With the advent of electronic medical records, the strategies have changed but human nature has not, as the VA study revealed.  Irresponsible and unethical health care providers continue to falsify records to conceal their shortcomings and blame others and, this is the important part, record falsification is not an isolated practice.  It is a common, recurrent, system-wide problem.

We Can Help

At Purchase, George & Murphey, P.C., our Pennsylvania medical malpractice lawyers recognize the challenges presented by medical records that sometimes conceal the truth. We perform a thorough investigation, including the use of electronic audit trail discovery and experts in the forensic analsyis of such data to help us ensure that the case is built solidly from the ground up. If you would like a free consultation with one of our experienced Erie medical malpractice lawyers, call today at 814-833-7100 or toll free at 814-833-7100.

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Allison, July 8, 2017