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Can a Medical Record Review Identify Falsification of Medical Records?

Medical Record Review

Most law firms encounter the issue of possible falsification of medical records while handling personal injury, wrongful death, and medical negligence cases. Falsifying medical records refers to altering, changing, or modifying a document purposely. Falsification may involve removing a diagnostic report, inserting information without standard documentation, rewriting or destroying the record, omitting significant facts, or even creating records for nonexistent patients or staff. Comprehensive medical review solutions performed by professionals can identify whether a record has been altered or not.

Accurate and complete medical records are essential not only to provide quality care and treatment in hospitals, but also for smooth legal proceedings. In a lawsuit, key evidence that indicates that a record has been altered can force the settlement of an otherwise defensible case. There is also the possibility that providers or nurses may create medical records that are unclear, incomplete or inaccurate and they realize the inadequacies only during a professional misconduct investigation or lawsuit.

With almost all hospitals implementing electronic health record (EHR) systems that document appropriate medical record changes and can track the person who accesses the record system, it is more difficult to interfere with records.

Alteration of a medical record can carry serious consequences. Medical records serve as important evidence in many legal cases. They contain key details such as patient’s medical history, the provider’s thought process, the basis for the diagnosis and treatment, communications with the patient and much more. Attorneys collect relevant medical records from claimants to support their argument in the court. If those records are left undated, illegible or incomplete, they can be used by a plaintiff lawyer to cast doubt upon the quality of care provided to the patient. A thorough review of medical records can distinguish falsifications if any, as the process looks for incomplete or doubtful information about the event that resulted in harm, or any disagreement between the documentation and what the patient has said; and compares progress notes with imaging reports, lab reports, pharmacy data and more.

Professional medical peer review solutions provided by experienced legal nurse consultants (LNC) focus on identifying any fraudulent documentation entries, as they know precisely what standard information the medical records should contain and can quickly identify missing, inconsistent, or out-of-order data. They can –

  • create an accurate timeline of the events in order
  • determine any inconsistencies in the records and identify any deviation from the standard of care
  • provide questions to ask in a deposition
  • summarize the testimony given on the record
  • identify missing or misleading information

Proper and accurate medical record organization and review can provide lawyers with a clear idea of any sort of alterations in the records and the various medical aspects involved in a case which will help them find the crucial evidence, understand the case details and thus prepare for the trial. Rather than maintaining an in-house team to conduct record review, it is a better alternative for busy legal firms to outsource the task to an experienced medical record review company. Such companies follow a step-by-step record review process that involves – record organization and indexing, preparing a clear chronology of events, creating brief or detailed summaries and more.

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