rewriting charts
In a case that I was involved with the office attempted to rewrite the records to improve their position.
the problem with doing that was that the chart became so different from all others in the office, which indicated the problems with the patient, and the attempts to justify what occurred.
By itself, a single chart may prove to be very difficult to show any alteration, but when compared with other charts, the differences in notes, documentation, narrative, show the problem.
With the new HIPAA regulations getting the records to show the differences might be more difficult, but could be accomplished by having all patient names and personal notations deleted.
It would then be pertinent to check the appropriate boards to see if any previous problems exist with this professional, and if there has been any legal case, it becomes important that those records be reviewed in regard to noting how the professional dealt with tose charts.
Not easy, but there are code sections about alteration of records with intent to deceive, and citing that part of the professional code, might be sufficient for a judge to allow those documents to become a part of any action you might consider.
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