It is an important practice for physicians to review medical records to check for accuracy and completeness.  Taking the time to amend medical records is a common practice.

Obviously, the best practice is to complete records correctly the first time.  However, physicians can make additions or corrections at a later point in time.  The key is to make the amendments in a legitimate manner.  Any amendments should be timely and not an apparent change.

Once a lawsuit has been filed or an attorney has requested records, it is too late to amend a patient’s medical records.   At this point, the plaintiff’s attorney most likely already has a copy of a physician’s records in their original form.  The jury will be shown both the original record and the revised record.  Anything a physician writes now could be viewed as self-serving or characterized as a cover-up.

Adding to a Medical Record

What should a physician do upon discovery that something has been left out of a medical record?  The physician should add to the record to show he or she reviewed the record and took care to add any missing information.

Correcting a Medical Record

What should a physician do upon discovery of an error in notes?  The physician should write a note to show that he or she is conscientious and concerned.  It is important to avoid using correction fluid to cover the original note, and to avoid erasing or obliterating any documentation in the record.  This would be characterized in court as an attempt to hide the facts.

Impact of Proper Amendment

It is very important for a physician to properly amend medical records correctly in the manner described above.  Any alteration will be detected by experts on handwriting, paper, ink and pen.  By making proper alterations, a physician will greatly reduce his or her liability in regard to insurance coverage issues, criminal charges, licensure problems, and malpractice.

Source, Lee J. Johnson, JD, Medical Economics, January 22, 2010.


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